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Personal details of individual or company representative.
(Select Broker for Agent Application)
  AssetPool      Health Pool      Member Account      (Indicate the % of allocations)
Company Registration
and Proxy
I hereby apply for membership in AEM Proviso Primary Co-operative Limited.
In the event of my application being approved by the Board of Directors, I agree to take up one share with a nominal value of R200.00 which amount will be deducted from my first contribution. I confirm that I subject myself to the stipulations of the current statute and rules and/or regulations, as well as any amendments which may be made to the statutes and the rules and/or regulations in future. I accept that I am responsible for informing myself about the working of the pools and/or accounts, by asking the management of the Co-op and am aware of the fees charged on transactions or monthly for payment of administration and other costs.
I understand that the Co-op does not offer insurance products but only assist members to recover from losses or costs incurred for which it makes provision for. It is noted that the entity comply with POPI Act 2013.
I have read and accept conditions of membership / Ek het die bepalings en vereiste gelees en aanvaar

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