Online Application Form

Online Application Form: R299 per household per month (2 members)

Title

First Name

Last Name

Cell Number

Alternate Phone Number

Residential Address

Postal Address

Suburb

Postal Code

Main Member ID Number

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 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

Preferred payment method

Credit Card Payment

EFT Payment

Joining Fee Payment - R399.00

Credit Card Payment

EFT

I accept terms & conditions

Terms and Conditions

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 members@rezcare.co.za.

Online Application Form: R299 per household per month (2 members)

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