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

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Comments or Special Requests

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Debit Order Payment

Credit Card Payment

EFT Payment

I accept terms & conditions

Terms and Conditions

Joining Fee Payment - R399.00

Include in my first month debit order

Credit Card Payment

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: R299 per household per month (2 members)

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