Online Application Title MrMrsMs First Name/s (required) Surname ID/Passport No Home Address Postal Code Postal Address Postal Code Contact Numbers Emergency Contact Your Email (required) Other Members of household Member 2: Member 3: Member 4: Member 5: Member 6: Joining-fee: Please debit my account on receipt of this application. Includes membership in the sign-on month. R330 (once-off per household) 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 Comments By submitting this form: I/we understand that CMR Membership only becomes valid when approved by CMR, and when the Joining Month Fee is received by CMR. I/we agree to subscribe to the service for two years in accordance with CMR's Standard Terms & Conditions. I/we confirm that I/we have read and understood the terms and conditions that apply to my relationship with CMR, and agree to the terms thereof. Banking Details Account in the name of: Bank Name Account Number Type Cheque Savings Preferred debit date 1st of month 15th of month 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 C.C. to debit my/our account with the monthly premium. I/we understand that the once-off Joining Fee includes membership of CMR for the joining month, with the first debit thereafter being made on the chosen debit date in the following month. I understand that if a debit order is returned for non-payment, a fee of R110,00 will be charged to cover CMR's bank and administrative fees.