NetworX - StudentPlan

MEDICAL DETAILSHave you ever received treatment for Chronic and / or Acute conditions?YesNoHave you received treatment for Chronic and / or Acute conditions in the past twelve months?YesNoDo you anticipate receiving any treatment for Chronic and/or Acute conditions in the next twelve months?YesNoAre you pregnant or suspect that you may be pregnant?N/AYesNoPlease indicate and provide details of any medical treatment you answered Yes to any of the above questions, please provide details below:NameDetails of conditionDate of treatmentDegree of recoveryStart dateEnd datePassport noDate of birthddmmyyyyPERSONAL DETAILS (To be completed in full)APPLICANT STATUSPLEASE NOTE: Copy of Institution acceptance letter, passport and proof of payment to be attached to this application formExisting Membership NumberRenewalNew ApplicantNetworX OptionConfirmation/Correspondance to be sent via: FaxEmailPeriod of membership(months)Method of Payment:CashEFTC redit CardRRRS urnameTitleMarital statusNationalityPresent agePostal codeSouth Africanpostal addressSouth African physical addressEmail addressStudy InstitutionStudent noCountry of OriginEmbassyGross Monthly IncomeRUniversal House, 15 Tambach Road, Sunninghill Park, SandtonPO Box 1411 Rivonia 2128 Tel: +27 86 122 2777 Fax: 086 645 4727E-mail: Website.

Name of bank Branch code - - BANKING DETAILS FOR CLAIMS RE-IMBURSEMENT BANKING DETAILS DISCLAIMER It is the member’s responsibility to advise the administrator in writing of any change in ...

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