Please select you province Western CapeEastern CapeFree State/Northern CapeKwaZulu-NatalNorthern/Highveld
Please select you Benefit (Required) Gold Membership - R41 per weekSilver Membership - R35.50 per weekBronze Membership - R20.50 per week
Surname ( Mr / Mrs / Ms ) (required) Marital Status: (required) SingleMarriedDivorcedWidowedDate of Birth (required) Please upload copy of your ID (file limit 2mb, file type: pdf,jpg,png)
Full Names (required) Maiden Surname (if applicable) Identity No. (required)
Postal Address
Tel Email Have you previously been registered as a member of MISA YesNo
Cell Your present Occupation (What is your Job Title at present) Membership No.
Name of Company (required) Street Address Email
Tel Postal Address Fax
The person whom the benefits, in terms of the Rules of MISA BENEFIT and FUNERAL FUND, shall be paid in the event of my death.
I hereby nominate Mr / Mrs / Ms (Surname) Marital Status: SingleMarriedDivorcedWidowedCell / Tel
Full Names I.D. No./Date of birth Relationship (Spouse, Son, etc.)
Address
Affiliate members of MISA need to pay subscriptions to MISA directly, in advance. Kindly note that the relevant waiting periods still apply.
MISA Active Member Contributions, Nedbank, Acc: 1513015354, Branch code: 198765. Kindly use your ID number or passport number as reference.*SUBSCRITIONS (2021): (required) Monthly: R125.673 x Monthly: R377.006 x Monthly: R754.00Annually: R1508.00
I, the undersigned, solemnly declare that the above particulars are true and correct, and I agree to abide by the Organisation’s Constitution and faithfully observe all rules and regulations which are in force, or may be brought into force, from time to time. Consent in terms of Act 4 of 2013 (Protection of Personal Information Act): I hereby authorise MISA to process my personal information (as per my membership application form) as well as to provide the necessary information of my MISA membership to my employer in so far as it is necessary to protect and/or execute my interests and/or those of MISA. PLEASE NOTE: It is your responsibility to notify MISA if and when any of your information changes regarding your membership. This includes your personal, company and beneficiary details.
Signature (please sign below with your mouse or finger)
Date (required)
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