Online Application

Title

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

Extra People (over and above the 6 included) @ R50 p/person p/month

Membership for Domestic workers who live off the property @ R66 p/person p/month


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.