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Date of registration: *

day

/

month

/

year

Principal Member

Name:*

First

Last

ID Number*

Your E-mail:*

Cellphone Number:

PLEASE NOTIFY US IMMEDIATELY IF YOUR CELL PHONE NUMBER CHANGES

Address:*

Street Address Postal Address City Province Postal Code

Vehicle Details

Vehicle Make:

Vehicle Model:

Vehicle Colour:

Vehicle Registration Number:

Who to contact if you are unable to answer?
ICE = In Case of Emergency

ICE Contact:

First

Last

ICE cellphone

2nd Person to contact if you are unable to answer?
ICE = In Case of Emergency

ICE 2 Contact:

First

Last

ICE 2 cellphone

Spouse Details

Spous Name:

First

Last

Spouse cellphone

Spouse ID Number:

Spouse E-mail:

Spouse Vehicle Details

Spouse Vehicle Colour:

Spouse Vehicle Make:

Spouse Vehicle Model:

Spouse Vehicle Reg Number:

Child 1 Detail

Child1 Name:

First

Last

Child1 ID:

Child 1 cellphone

Child1 E-mail:

Child 2 Detail

Child2 Name:

First

Last

Child2 ID:

Child2 E-mail:

Child 2 cellphone

Child 3 Detail

Child3 Name:

First

Last

Child3 ID:

Child 3 cellphone

Child3 E-mail:

PLEASE NOTIFY US IMMEDIATELY IF YOUR CELL PHONE NUMBER CHANGES

Recurring payment:

Recurring Monthly EFT

EFT

Select Membership Option - excluding the once off fee of R 40

Do you have Medical Aid?

YES

NO

If YES, Which Scheme (Name):

Please state any serious medical conditions:

Do you have ARMED RESPONSE Service?

YES

NO

If YES, please complete the following fields

Name of Armed Response Company (that we can contact if you can not)

Armed Response Control Room Contact Number

Customer / Account Number with Armed Response Company