To join Labour Protect, simply complete the following details below.  (Once the first payment of R85.00 is deducted off your specified account, we will forward to you your personalized Premier Membership Card.)  We look forward to have you as one of our many satisfied Members...

                                                                                                              Referred by (if applicable): 

APPLICATION FORM:

PERSONAL DETAILS

First Name:             Surname:             Title:  

Postal Address:                   Postal Code:  

Physical Address:  

Identity Number:          Email Address:  

Telephone Area Code:         Telephone Number:             Cell Phone Number:  

DEBIT ORDER DETAILS

I wish R85.00 to be deducted each month by debit order on my bank account.  (I will notify Labour Protect in writing should I wish to cancel this instruction and/or cancel my Membership.)

Date of Preferred Deduction:        1st        15th         25th

Name of Bank:                Branch:  

Branch Code:                Account Number:           

Type of Account:              Savings        Transmission        Cheque Account