203 Beyers Naude Drive , Northcliff
Tel: 011 888 4681 Fax: 011 782 0270
APPLICATION TO SUBSCRIBE FOR SHARES CONFIDENTIAL
I, the undersigned ______hereby apply to take up shares in the Faculty of Consulting Physicians of South Africa Limited (the Company), the object of whichis to negotiate with the funders of health care, managed care organisations, other health care providers and the suppliers of goods and services to the respective shareholders of the Company, with a view to maximising the potential synergistic and rationalisation benefits for each shareholder. I acknowledge that the Articles of Association of the Company are available for my inspection and I agree that the board may use the pharmaceutical/ claims data as a means of enhancing the group.SIGNED at ______this ______day of ______2008.
COSTS:
1. R10for the purchase of 1 (one) share in the company.
2. R228 (inc VAT)thereafter, per month, for management fees, payable to the Faculty of Consulting Physicians of South Africa Limited by stop order.
Shareholders’ information, to be completed by each partner
NOTE: The below information is necessary in order to prepare a complete shareholders’ database.
Please complete in full. Retain a copy for your records
GENDER / MALE FEMALE
SURNAME
FIRST NAMES
POSTAL ADDRESS
PRACTICE ADDRESS (Physical)
PRACTICE NUMBER (BHF)-(PCNS)
HPCSA REG. NUMBER
IDENTITY NUMBER
VAT REGISTRATION NUMBER
ARE YOU A PAID UP MEMBER OF SAMA? / YES NO
PRACTICE TELEPHONE NO.
PRACTICE FAX NO.
CELLULAR PHONE NO.
E-MAIL ADDRESS please print clearly
Hospitals at which you practice (include day clinics and Medicross)
TYPE OF DISCIPLINE / Dermatologist Rheumatologist Pulmonologist Physician Neurologist Nephrologist
TYPE OF MEMBERSHIP / Private Practice FullTimeHospital Practice Registrar Other Specify:______
ARE YOU INTERESTED IN FURTHER INFO ON: / ABSA ALEXANDER FORBES MEDIGRO
PREFERRED METHOD OF COMMUNICATION: / EMAIL FAX
PLEASE FAX BACK TO 011 782 0270
Faculty of Consulting Physicians of South Africa LtdUnit 16 NorthcliffOffice Park203 Beyers Naude Drive , Northcliff
Tel: 011 888 4681 Fax: 011 782 0270
ACB AUTHORITY
I hereby request that you make withdrawals from my bank account on the date(s) specified below or at any other time stipulated in the event of the transfer not being made.NAME OF ACCOUNT HOLDER
PRACTICE NO.
BANK DETAILS
TYPE OF ACCOUNT / CURRENT: SAVINGS:
NAME OF BANK
BRANCH
ACCOUNT NO.
BANK CLEARING CODE
(top right corner of cheque)
INITIAL AMOUNT (R228 inc VAT) IN
MONTH: / DATE:
THEREAFTER AMOUNT (R228 inc VAT)
TO BE CHARGED MONTHLY FROM: / DATE:
The company will charge my account on the 1st (first) and on the same day of each month thereafter. It is hereby agreed that this authority will remain in force until cancelled in writing.
SIGNED AT: ______on ______2008.
SIGNATURE: ______
PLEASE FAX BACK TO (011) 782 0270
Please attach a cancelled cheque
1