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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.
I have read and accept conditions of membership / Ek het die bepalings en vereiste gelees en aanvaar

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