Form No.

Z/2021/AF – 002

FULL MEMBERSHIP APPLICATION FORM

All application correspondence to:
FOR OFFICIAL USE ONLY
Zambia Occupational Health and Safety
Suite 115B David Mwila House, behind ZMart Shop, CBD Kitwe Processed by: Passport
P.O. Box 22836 Date: Size
Kitwe – Copperbelt Province (Zambia). Signature: Photo
Phone: +260 963 922 125 /+260 966 608 258/+260 977 642 804 Approved: Yes or No
E-mail: zohsa.secretariat@gmail.com Date Admitted:
Solwezi office: +260 969 670 875 Lusaka Office: +260 966 608 258 Membership No.:

IMPORTANT NOTES FOR APPLICANTS

Please read through the notes provided below before proceeding with the filling of the application form contact ZOHSA
Secretariat Should you need further clarification or assistance.

Applicants must submit the requirements as stipulated below for the application to be processed.

a. Certified copies of professional qualifications in the field of Occupational Health and safety management from
the recognised institution.

b. Curriculum Vitae.

c. Certified copies of National registration card or passport.

d. A passport size photo, to be placed on the cover page of the application.

e. Completed application forms (Please pay attention to the seconders and proposers section).

f. All fees must be paid into the Association accounts and submit deposit slip to the secretariat.

g. Processing and verification fee of K20 is non-refundable.

h. Membership with Zambia occupational health and safety association (ZOHSA) does not automatically warrant
any person a job opportunity or to obtain a work permit in an event of foreign nationals.

i. All foreign nationals working in Zambia who are applying for membership must attached proof of valid work
permit to the application form.

j. The Zambia Occupational Health and Safety association reserves the right to withdraw membership of any
individual who goes against the code of conduct and ethics of the association or should it be found that the
documents submitted at the time of application lacked authenticity.

k. Processing of the application takes five working days when form is fully completed and documents submitted
are easily verifiable.

l. Initial registration fees must be deposited into the association account number 0092030000353 at Indo –
Zambia Bank.
Processing and verification fee K20
Membership fee K300

L. Membership Certificate will only be issued out upon payment of all the fees in full. All fees are non-refundable

Zambia Occupational Health and Safety Association – Towards improved safety standards for sustainable development
SECTION A: PERSONAL DETAILS (Please use CAPITAL /BLOCK letters when filling in this form)
Surname Other Name (s)

First Name Title (Prof./Dr./Mr./Miss./Ms.) Sex (M/F)

NRC /Passport No. Date of Birth

Nationality Tel. No. Cell No.

Physical Address
Email Address Fax No.

Name of current employer

Current Employer’s nature of business (e.g. Mining / Consultancy / Transport/ Training/Commercial etc)
Address for current employer

Current Job Title

Professional Qualification (Degree / Diploma / Certificate / Other Qualifications. attached all copies of your qualification to this application).
Title of Award Field of Specialisation Institution Completion Year

Membership to other Professional Institution (attach proof of registration)

Institution Country Class of Membership Membership No. Date Attained

Details of the Professional Institution (at least one)

Postal Address

Tel. No. Fax No.

E-mail Address Website

SECTION B: DETAILS OF THE COLLEGE / UNIVERSITY ATTENDED

Name of College / University: From: To:

Postal Address:
E-mail Address: Fax No.:

Tel. No.: Website:

Zambia Occupational Health and Safety Association – Towards improved safety standards for sustainable development
SECTION C: PROPOSER’S AND SECONDER’S CONSENT
We the undersigned present this application and agree that the applicant is worth for the membership applied for. We hereby certify that particulars in the
application form and attachments hereto are true in every respect. Only Fully paid up registered members of ZOHSA are allowed to sign in this section.
PROPOSER
Name: Membership No. Class
Address
Cell No.: Fax No.: E-mail
Office No. Date Signature
SECONDER
Name: Membership No. Class
Address
Cell No.: Fax No.: E-mail
Office No. Date Signature

NOTES TO PROPOSERS AND SECONDERS

I. The Proposer and Seconder should be fully paid up members of the Association who are familiar with the candidate’s work in the last one year in
the applicant’s country of residence.
II. The Proposer and Seconder must ensure that the candidate has the necessary academic and professional qualifications and experience for the
Class of membership being applied for.
III. The Proposer and Seconder must ensure that all accompanying copies of certificates are certified by appropriate legal authorities as true copies
of the original.
IV. All foreign nationals working in Zambia must have valid work permit which must be provided together with the application forms.

I (applicant). ........................................................................ do hereby declare that I will abide by the fundamental principles
and canons enunciated in the code of conduct and ethics of the Zambia Occupational Health and Safety Association (ZOHSA)
and that information submitted is true and correct.

Signature: ............................................................ Date: ...........................................................

To be completed by Secretariat Official.

Date application Submitted:……………………………….

Received by:………………………………………………………. Stamp.

Time:……………………………………………………………………

Signature:……………………………………………………………

Zambia Occupational Health and Safety Association – Towards improved safety standards for sustainable development