MEMBER APPLICATION FORM

FOR OFFICE USE ONLY

Membership Number

Group Reference Number

Date of Commencement

Resolution Health Medical Scheme - 086 111 7376

MEMBER APPLICATION FORM

Notes: A separate application must be completed for each additional adult dependant i.e. other than your spouse/partner. Please see application for the Registration of Additional Dependants form. Faxed copies will not be accepted.

* COMPULSORY FIELDS

A. DETAILS OF APPLICANT

* Surname	Title
* First names (in full)	Initials
* I.D. Number
Date of Birth	* Gender	Male Female
Employer Name
Employee Number	Branch
Occupation Full Details
Date of Employment	Language
Income Tax Number

B. FAMILY MEMBERS TO BE INCLUDED - Please attach copies of the following:

1) Dependant children or other members to immediate family in respect of who, the member is liable for care and support

2) Adult dependat - 21 years and older to complete "registration of additional dependant" application form

A. Dependants
Dependant type	Spouse Child
Surname
First name(s)
Initials		Title
ID Number
Date of Birth		Age
Gender	M F
Relationship to Applicant

B. Dependants
Dependant type	Child
Surname
First name(s)
Initials		Title
ID Number
Date of Birth		Age
Gender	M F
Relationship to Applicant

C. Dependants
Dependant type	Child
Surname
First name(s)
Initials		Title
ID Number
Date of Birth		Age
Gender	M F
Relationship to Applicant

D. Dependants
Dependant type	Child
Surname
First name(s)
Initials		Title
ID Number
Date of Birth		Age
Gender	M F
Relationship to Applicant

C. CONTACT DETAILS
Residential Address	Postal Address

Code	Code
Telephone (W)	Cell
Telephone (H)	Fax
Email Address
SMS Correspondence Yes No