Attention: WEB Registration
Fax: (031) 5800485

Please type within the fields provided and then print, sign and fax this form to MMSA. If you have any trouble filling in this form, an example with help is available.
Member number: (if applicable)
Practice number: (if applicable)
Group number: (if applicable)
Intermediary number: (if applicable)
Home telephone number:
Work telephone number:
Fax number:
E-mail address:
Preferred User Name:
(Member, Practice, Group or Intermediary number will be used if this is left blank.  If your preferred Username is not available, the Webmaster will allocate you a unique username.)

Group Members - Please ask your Human Resources or Finance Manager to verify the details and then sign and stamp the form with the Company Stamp.
Individual Members - Please be aware that if you are applying for individual member access,you only need supply your member number.

After verifying your details, we will allocate you a password to use in conjunction with this User Name. We will then email you your registered User Name and Password.

I accept that MMSA will not in any way be responsible or liable for any claims of any nature whatsoever made by anyone (myself included) which arise as a result of my failing to keep my password and user name secure and confidential to myself. I indemnify MMSA and hold it harmless against any such claims.
I understand that this service may not be available 24 hours a day.

(Print out the form and then sign here)