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Application

A: Main Member Details
A1 First name
Surname
Contact Details:
Tel:
Fax:
Email:
ID No:
Medical Aid Fund:
Medical Aid Fund #:

B: Additional Members Details
B1 First name
Surname
ID No:
Medical Aid Fund:
Medical Aid Fund #:
B2 First name
Surname
ID No:
Medical Aid Fund:
Medical Aid Fund #:
B3 First name
Surname
ID No:
Medical Aid Fund:
Medical Aid Fund #:
B4 First name
Surname
ID No:
Medical Aid Fund:
Medical Aid Fund #:
B5 First name
Surname
ID No:
Medical Aid Fund:
Medical Aid Fund #:

C: Vehicles
C1 Vehicle Make
Registration #:
Trailer Registration #:
Owner:
C2 Vehicle Make
Registration #:
Trailer Registration #:
Owner:
C3 Vehicle Make
Registration #:
Trailer Registration #:
Owner:

D: Membership
  Select Membership:
 One Month
One Year
Multiple
  Membership
Start Date:
dd/mm/yyyy

E: Terms Conditions

By submitting the application form and paying the membership fees, I acknowledge that obtaining membership and paying membership fees does not entitle me to any free services in Mozambique or South Africa. I also acknowledge that membership is merely a service that will bring me in contact with service providers . Mozhelp, Mozassist and Noodroep can’t be held liable for any injuries or death caused by action or lack thereof by any of their service providers.

I Agree to the Terms and Conditions

 

Please deposit the membership fee into the account specified below

GOLDEN FALLS TRADING 224 (PTY) LTD
ABSA NELSPRUIT
4060708303
BRANCH : 632005

Please fax proof of payment to:

FAX NO: 013 7900427
or

Please use your ID number as our reference number.

puts the assistance in Mozambique