New Registration

Personal details of individual or company representative.

Account Name (e.g. Jan de Wet or Traders Inc(Pty) Ltd.)

Registration Number (if applicable)

Member Type

(Select Broker for Agent Application)

Title

Names

Last Name

Call Name

Work Phone Number

Fax Number

Home Phone Number

Mobile Number

E-Mail Address

Language Preference

Contact Preference

Gender

ID Number

Birth Date

Address Type

Address Line 1

Address Line 2

Address Line 3

City / Suburb

Post Code

Province

Country

Date of First Deposit		Deposit Allocation
Deposit Amount		AssetPool Health Pool Member Account (Indicate the % of allocations)
Method
Proof of Payment(if any)
ID Document		Proof of Address
Bank Statement		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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