Membership Checkout

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Membership Information

You have selected the PCSA Member membership level.

The price for membership is R 1,800.00 now.

Account Information

Username

Password

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Email Address

Confirm Email Address

Full Name LEAVE THIS BLANK

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Family Information (Spouse and Children)

Spouse Title

Spouse - Name and Surname

Spouse - Date of Birth

Spouse - ID Number

Spouse - Email

Spouse - MSA License No

Spouse - Cell No

Spouse -Work No

Spouse- Fax No

Spouse -Home No

1st Child - Name and Surname

1st Child - Date of Birth

1st Child - Gender

1st Child - Contact No

2nd Child - Name and Surname

2nd Child - Date of Birth

2nd Child - Gender

2nd Child - Contact Number

3rd Child - Name and Surname

3rd Child - Date of Birth

3rd Child - Gender

3rd Child - Contact Number

Main Member Information

Title

Date of Birth

Occupation - Industry Type

ID Number

MSA License No

Work No

Fax No

Home No

Membership Starting Date

Emergency / Medical Information

Medical Aid Name/Scheme - Member

Medical Aid Number - Member

Medical Aid Name/Scheme - Spouse

Medical Aid Number - Spouse

Blood Type - Main Member

Blood Type - Spouse

Any Medical Condition - Member

Any Medical Condition - Spouse

Emergency Contact Person - Name and Surname

If your spouse’s details have already been submitted, please avoid adding them again as your emergency contact and instead provide an additional contact person, in case of emergency where both members (you and your spouse) are involved in an incident.

Emergency Contact Person - Phone Number

2nd Emergency Contact Person - Name and Surname

2nd Emergency Contact - Phone Number

Vehicle Information

Vehicle 1 - Model

Vehicle 1 - Year

Vehicle 1 - KW

To convert HP to KW divide HP value by 0.7457

Vehicle 1 - Colour

Vehicle 1 - Tyre Type

Vehicle 1 - Weight

Vehicle 1 - Registration No.

Vehicle 1 - Insurer

Vehicle 1 - Has the vehicle been modified or is it standard?

Vehicle 1 - Modifications / Notes

Vehicle 2 - Model

Vehicle 2 - Year

Vehicle 2 - KW

To convert HP to KW divide HP value by 0.7457

Vehicle 2 - Colour

Vehicle 2 - Tyre Type

Vehicle 2 - Weight

Vehicle 2 - Registration No.

Vehicle 2 - Insurer

Vehicle 2 - Has the vehicle been modified or is it standard?

Vehicle 2 - Modifications / Notes

Vehicle 3 - Model

Vehicle 3 - Year

Vehicle 3 - KW

To convert HP to KW divide HP value by 0.7457

Vehicle 3 - Colour

Vehicle 3 - Tyre Type

Vehicle 3 - Weight

Vehicle 3 - Registration No.

Vehicle 3 - Insurer

Vehicle 3 - Has the vehicle been modified or is it standard?

Vehicle 3 - Modifications / Notes

Indemnity

By updating My Profile I , the undersigned, hereby agree that membership of the Porsche Club of South Africa – Central Region (The Club) is granted on the specific condition that neither The Club nor any of its office bearers shall be liable for any injury, loss or damage of whatsoever nature and howsoever caused, whether due to the negligence of The Club or any of its members or not, whether such damage, injury or loss is sustained on premises used, leased or owned by The Club or not, or whether such damage, injury or loss is sustained during an event organized by The Club or under its auspices or not. I/We hereby accept membership of The Club under the rules as set out in its constitution and the indemnity contained above. I Accept

Billing Address

First Name

Last Name

Address 1

Address 2

City

State

Postal Code

Country

Phone

Payment Information

Card Number

Expiration Date

Security Code (CVC)

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