QABSO BURIAL SOCIETY CO-OPERATIVE
Membership Agreement Form
Applicant Information:
{Please print carefully}
Member Surname: ________________________________________
Full Names: ____________________________________________________________
Identity Number: _________________________________________
Nick Name: ____________________________________________________________
Postal Address: __________________________________________
Residential Address: ____________________________________________________
___________________________________________
____________________________________________________
___________________________________________
____________________________________________________
_
Code:
_____________________
Province:
___________________________________________
Tell: No: {H}
Code: _________________________
______________________________ 1st Cell: _________________________________
Email Address: ______________________________
Marital Status: _______________________________
Fax: ___________________________________
2nd Cell: ______________________________________
Tell: {w}:_____________________________________
Gender: ______________________________
Level of Education: _______________________________________
Organisation Belonging to: ______________________________________________
Type of Income:
Recruited By: _________________________________________________________
_______________________________________
Spouse / Beneficiary Details:
Member Surname: ________________________________________
Full Names: ___________________________________________________________
Identity Number: _________________________________________
Nick Name: ___________________________________________________________
Postal Address: __________________________________________
Residential Address: ___________________________________________________
___________________________________________
____________________________________________________________
___________________________________________
____________________________________________________________
___
Code;
______________________
Code: ___________________
Relationship:
___________________________________________
Details of immediate family:
Full Names and Surnames
Gender
Identity Number
Age
1
2
3
4
5
6
7
8
9
10
11
12
Extended family:
Full Names and Surname
1
2
3
4
5
Additional family:
Full Name and Surname
1
2
3
4
Gender
Identity number
Identity number
Relationship
Age
Relationship
Qabso Burial Society Co-operative
Bank Details
Bank Name: ___________________________________________________
Type of Account: ________________________________
Account No: ____________________________________________________
Branch: ____________________________________
Code:_______________________________
Payment Arrangements
Joining fee is R300.00
Monthly Subscription R168.00c
Waiting Period of 9 Months:
- Additional Fees: __________________________
Starting Date________ / _______ / 20_______
Completion Date: ________ / _______ / 20_________
System of Payment: ______________________________ (Nobody is allowed to receive money from members)
Annual renewal membership fee R170.00
Member Declaration
I _____________________________________ agree with the burial society that the joining fee and monthly contributions are non-refundable. I hereby, declare
that I have read the declaration on this part and reverse page. I agree and understand the procumbent of this part. Furthermore, I know that this Burial
Society is a legal society operating under the Co-operative Act No6 of 2013. And Qabso Constitution no: 2008 / 00468 / 24
I know that should I fail to contribute continuously my benefits will forfeit for 3 months (90 months)
I sign ______________________________________
Date: _____ / ____ / 20_______
Witness: ___________________________________
Qabso Rep Signature: _______________________ Date: _______ / ______ / 20________
NB: If you fail contribute; you are forced to be part of catering team
Special rules and regulations
1.
If a member had claimed for a funeral, it is compulsory that she/ he shall contribute with two people to join the Burial Society, before he/she can
claim for the second funeral.
2.
If the member fails to recruit two members she/he will contribute with R1 800.00 to raise funds for the people’s burial society.
3.
A member must sign a claim form, with the signatory of the second family member who shall take over the file in future.
4.
If a member allows his /her family members to fight/ grumble with the Society or Officer she/he shall be fined R1 200.00, for his/ her failure to
protect your burial co operative
5.
If the member use a debit order means of payment, it upon the member ensure that sufficient funds are available in her account.
6.
Charge of Address and contact details shall be reported to office in time, it the members fault should the members be unreachable due to charge
of contact details and address of the member, hence the office shall not be held liable for letter, SMS’s and calls which did not reach the member.
7.
All members must be in possession of Co-operative Act No6 of 2013 Qabso policy co-operative regulators. This is compulsory to all members.
8.
The Burial Society needs two working days to prepare for funeral arrangements, after receiving a Death Certificate.
FOR OFFICE USE ONLY
Agent Membership Number: _______________________________________________
Agent: _________________________________________________
Province: _______________________________________________________________
Town: __________________________________________________
Membership Approval Date: _______________________________________________
Approved by: ___________________________________________
Signature: ______________________________________________________________
Waiting Period: __________________________________________
Termination: ____________________________________________________________
Terminated by: __________________________________________
Signature of Terminator: __________________________________________________
Witness: _______________________________________________