Registration

Complete the form below to join NAPTOSA

"*" indicates required fields

Choose your Province*

Name*

Title and Initials*

ID Number*

Date Of Birth*

Cellphone Number*

Personal Email Address*

Full Home Address*

Please remember to include your postal / residential code!

Name of School / College / Office*

Employment / Membership Type*

Persal / Employee Number*

SACE no

Branch & District*

Physical Work address*

Please include the postal / residential number!

Please select an option below for your membership application:*

Please specify your job title e.g. Teacher, Psychologist, Therapist, Nurse, General Assistant etc.*

Were you recruited by a NAPTOSA Member?*

Recruiter Membership no (if applicable)

Recruiter Name & Surname

How Many Dependents Do you Have?*

Please state the number of dependents

Please Provide Us With All Your Dependents Full Names, Surnames, ID Numbers and Contact Details:*

Beneficiary Nomination Consent*

Please note that this form includes your Funeral Beneficiary nomination and by signing the form you declare that you understand that this beneficiary nomination cancels all previous nominations, if any, that you have made with respect to the NAPTOSA Funeral Scheme payable by SAFRICAN.

I hereby nominate the following person as the beneficiary of my NAPTOSA Funeral benefit in the event of my death: (NOTE: The Funeral Benefit will be paid into your estate if we do not have a valid Beneficiary Nomination form)

Agree

Do Not Agree

Main Beneficiary Details*

ID/ Passport number*

Date Of Birth*

Relationship*

Contact Telephone No*

Personal Email Address*

Secondary Beneficiary Details:*

In the event that the main beneficiary nominated above has passed away before the effective date of my death, they will be excluded from receiving the portion he/she was nominated to receive, and the following nominated beneficiary will receive any benefits payable:

Agree

Do Not Agree

Secondary Beneficiary Details:*

ID/ Passport number*

Date Of Birth*

Relationship*

Contact Telephone No*

Personal Email Address*

Bank Details:*

Name Of Bank?

Account Number?*

Please provide your account number that you'd like to be debited with your monthly premium?

Type Of Account*

Please provide the type of account you'd like to be debited with your monthly premium?

Name Of Account?*

Please specify the name of the account?

Branch*

Please specify the branch name and branch code of your bank where your account is held?

Debit Order Date*

Select Debit Order Date

For Office Use

NAP Member Code

Date Uploaded to Q LINK:

Date

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