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Online Application Form: RezCare SOS - R499 pm

Title

First Name

Last Name

Cell Number

Alternate Phone Number

Residential Address

Postal Address

Suburb

Postal Code

Emergency Contact Name (not someone on this membership)

Emergency Contact Number

2nd Emergency Contact Name (not someone on this membership)

Emergency Contact Number

Co-Member Name

Co-Member Date of Birth

Start Date of Membership

Immediate Cover: I agree to pay pro-rata for the joining month by one-off debit on the date of commencement of this membership

Please contact me to discuss a different start date and/or a different payment method for the first month

How did you hear about us?

Comments or Special Requests

Person Responsible for Account

Account Holder Name

Account Holder Contact Number

Account Holder Email

Bank Name

Account Number

Type of Account

Cheque / Current

Savings

Preferred Debit Order Date

1st of the month

15th of the month

Please check each box to show your agreement to the statements below:

By submitting this form, I/we agree to subscribe to the service in accordance with RezCare's Standard Terms & Conditions which are available on request and on the RezCare website: www.rezcare.co.za I/we confirm that I/we have read and understood the terms and conditions and agree to the terms thereof

I/we hereby authorize RezCare (Pty) Ltd to debit my/our account with the total monthly premium indicated above. I/we understand that a charge of R110 will be levied for any debit-order non-payment/s.

Thank you for submitting this application form. Should you not hear from us within 24 working hours - please call our support centre on 087-654-3177 or email .

Online Application Form: RezCare SOS - R499 pm

Person Responsible for Account

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