Household Application

Title

First Name/s (required)

Surname

ID No

Home Address

Code

Postal Address

Code

Contact Numbers

Local emergency contact

Your Email (required)


Other Members of household

Member 2:

Member 3:

Member 4:

Member 5:

Member 6:


Once-off joining-fee: NOT APPLICABLE IN SEPTEMBER DUE TO SPRING SPECIAL!! Please check R0 box below.


Monthly Membership Fees

Hospital Transportation Cover

Extra Person (over and above the 6 included) @ R40 p/person p/month

Membership for Domestic workers who live off the property @ R55 p/person p/month

Extra B&B beds. Paramedic Service only @ R27,50 p/bed p/month


Banking Details

Account in the name of:

Bank Name

Account Number

Type

Preferred debit date

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 starting in the month following signature date below. I/we understand that the once-off Joining-Month Fee includes membership of CMR for the joining month, with the first debit being made on the chosen debit date in the following month or month thereafter.
I agree


By submitting this form:

I/we authorize Cape Medical Response CC to debit my/our account with the monthly premium indicated above starting in the month following submission of 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 understand that if a debit order is returned for non-payment, a fee of R90,00 will be charged to cover CMR's bank and administrative fees.
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. (View CMR's Standard Terms & Conditions here)