CHESSA Registration 2007 for Gauteng Juniors

Before filling in this form, please deposit R50 (for Juniors 20 years or less) or R100 for Seniors into the following Bank Account:

(New Bank Account 22/02/2006)

Bank:                       Standard Bank
Account Name:        North West Rand Chess Association
Account number:     00 207 571 7
Branch:                    Rosebank 4305

Please make sure you have your bank deposit slip ready before submitting this form.

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Banking Details

Deposit date: (yyyy/mm/dd)
City where deposited:
Reference:

Personal Details

ID Number:
Surname:
Initials:
Firstname:
Second name:
Third name:
Title:
Date of Birth: (yyyy/mm/dd)
Type:
Race:
Sex:

Contact Details:

Address:


Postal Code:
Union:
Tel (h):
Tel (w/b)
Fax:
Cell:
Email: