AHPCSA Registration Form

Title*

First Name*

Last Name*

E-mail Address*

Confirm E-mail Address*

Phone Number

Password*

Confirm Password*

Confirm Professional Council Registered with*

Profession*

Professional Council Number*

City*

Guidelines for a strong password:

At least 8 characters—the more characters, the better.
A mixture of both uppercase and lowercase letters and a mixture of letters and numbers.
Inclusion of at least one special character, e.g. ,! @ ? ]#

Only fill in if you are not human