Online Application Title MrMrsMs SA ID No/DOB Home Address Suburb/Area Postal Address Postal Code Cell/Tel Nos Emergency Contact Emergency Contact Your Email (required) Co-Members included Member 2: Member 3: Member 4: Member 5: Member 6: Monthly Membership Fees CMR Household Membership WITH Hospital Transport Cover: R360 per household per month (6 people max - see pricing below for additional people living on premises)Pensioners' Household Membership WITH Hospital Transport Cover: R335 per household per month (max 2 people, at least one person must be 65 or above) CMR Household Membership WITHOUT Hospital Transport Cover: R255 per household per month (I understand the cost of ambulance transport to hospital will be billed separately if/when required)Pensioners' Household Membership WITHOUT Hospital Transport Cover: R230 per household per month (I understand that the cost of ambulance transport to hospital will be billed separately if/when required) Extra People (over and above the 6 included) @ R50 p/person p/month 0123456789 Membership for Domestic workers who live off the property @ R66 p/person p/month 0123456789 NB: Membership becomes active on receipt of your first fee payment. If not otherwise instructed, we will activate the membership and debit fees on receipt of the application. Notes By submitting this form, I/we agree to subscribe to the service for two years in accordance with CMR's Standard Terms & Conditions which are available on request and on CMR's website: www.cmr-med.co.za I/we confirm that I/we have read and understood the terms and conditions and agree to the terms thereof. Banking Details (If the primary member is not the account payer, then please record the payer's name and details at the bottom) Account holder: Bank Name Account Number Type Cheque Savings Preferred debit date 1st of month 15th of month First Monthly Debit: Account contact person (if different to main member) Contact Number (if different to main member's) Email (if different to main member's) I/we hereby authorize Cape Medical Response to debit my/our account with the total monthly premium indicated above, and in the starting month indicated above. I/we understand that a charge of R120 will be levied for any debit-order non-payment/s.