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Administered by: Status Medical Aid Administrators (Pty) LtdReg. Number 1974/001443/07 Registered Office: Status House, 15 Tambach Road, Sunninghill Park, SandtonPrivate Bag X131, Rivonia 2128 Tel: (011) 208 1000 Fax: (011) 208 1028 E-Mail: Kindly complete the application form and submit to the Human Resources Department. NEW application NEW DEPENDANT Name of Individual Inception / Start date Name of Company OPTION A OPTION B OPTION C FOR OFFICE USE ONLY Member Number Firm Code Race (for statistical use only) Language Subs table Persal Number Code Please attach a certificate of membership from the previous Medical Aid Scheme(s) to this application TIGER BRANDS MEDICAL SCHEME Registered in terms of the Medical Schemes Act (No.)

Please attach a certificate of membership (from the previous medical scheme) to this application. Applicants wishing to join at a date after

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