I/we hereby confirm the purchase of a CMRLifeLine unit @ R2500 incl VAT.

I will pay by:CashEFTCard

I/we understand that R55 per unit per month incl VAT will be added to my monthly CMR membership fee for the Network Provider Fee

Name of person placing this order:

Email address of person ordering:

Phone number of person ordering:

SMS’s

Whenever the CMRLifeLine unit is activated, an SMS should go to:

Please use names of people who live close to the holder, or may know their daily movements.

I/we understand that,

• CMR’s standard T&Cs apply to all services, that the above service can be canceled at any time on
  one month reciprocal written notice, and that rates increase on the 1st April each year.

• CMR is only an agent for MyLifeLine units, and that any faults or product problems will be passed onto
  MyLifeLine. MyLifeLine’s Terms of Service can be viewed at https://mylifeline.co.za/policies/terms-of-service.

• CMR shall not be liable in any way for any loss or damages resulting from any faults or product problems,
  including the receipt or non receipt of any signal/s sent from my/our MyLifeLine unit.

• ownership of the unit passes onto me/us on delivery, and that it is my/our responsibility to ensure that the unit is
  sufficiently charged at all times, and that the unit only communicates any low battery warnings to the cell number/s
  I/we have provided.

• my/our membership in CMR must be current in order for CMR to provide any services to me/us or for CMR
  to receive any signals from my/our MyLifeLine unit.

• if my/our MyLifeLine unit is not charged for an extended period (approximately two months) that the unit’s SIM
  card will expire, and any costs associated with the purchase of a new SIM card will be for my/our account.

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By submitting this form I/we hereby authorize Cape Medical Response to debit my/our account with the total monthly premium indicated above. Please note that on accounts requiring more than one signatory, proof must be provided of authority to sign on behalf of all the account holders.