New Member Registration

 
 
IC Code: 00-07703 Recruiter Code:
* Please enter Recruiter's number (if any)
Surname:  * Postal Address
Line1:
First Names:  * Line2:
Known As:  *Compulsory City:
ID Number:  *No Spaces Post Code:
Phone (Day): Residential Address
Line1 :
Phone (Night): Line2 :
Mobile:  *No Spaces City :
Fax: Province :
eMail: Post Code:
    Gender :

Payment Method:
None
Cash
Debit Order
Internet Transfer
Credit Card
Bank Details Employment Details
Account Holder:
Employer:
Bank:
Employer Address:
Branch:

Branch Code:

Account Type:
Department:
Account No:
Employee No:

Date of deduction:
0 1 5 15 20 25 26 28 Last Day

Interested in Income Opportunity:
None No Yes

Month in which to Start Deduction:
None 1 2 3 4 5 6 7 8 9 10 11 12

 

Dependants
  Name Relationship ID No / Birth Date
1
2
3
4
5
6
7
8
9
10
Please note that a once-off R80,00 administration fee will be deducted with your first premium.

Please note that the ip address of this computer is being captured. If you are not the person taking out the membership or the bank account holder whose name appears above then a signed application form needs to be posted or faxed to us by the person applying for this cover to prevent repudiation of claims in future. Please post the signed application form to MultiSure (Pty) Ltd, PO Box 63943, Greenacres, Port Elizabeth 6057 or fax to 041-363 1479.