Organisation

Postal Address

Phone

Email Address

Contact Person

Position

Contact Phone

Contact Cell

Contact Fax

Contact Email

Registration Type (NPO, Section 21 Company, Trust etc)

Organisation Main Aims

Affiliated to Larger Organisation Affiliated to Larger Organisation Yes No

If YES which organisation

Do your services extend to more than 1 province? Do your services extend to more than 1 province? Yes No

If YES which provinces

One Province One Province Yes No

If YES which province

Region within 1 Province Region within 1 Province Yes No

If YES describe the area

A specific Local Area? A specific Local Area? Yes No

If YES Name the City area or Magisterial district

is the organisation committed to transformation in terms of its governance, personnel and beneficiaries of services? Answer Here

Does the organisation have a transformation plan? Answer Here

What are your expectations from becoming a member of NACOSS? Answer Here

Where / from whom did you hear about NACOSS? Answer Here

Any other information or comments?

Your Name

Date (yyyy-MM-dd