New Membership Form

1. General
2. Attachments
3.Spouse
4. Employment
5. Banking Details
6. Funeral Benefit
7. Dependent
8. Medical Info
9. Ill Person
10. Finish

Member Type

Cover Option

Marital Status

Title

Initials

Surname

First name(s)

Date of birth

Sex

Related To Pip

NoYes

Elaborate On Pip

ID or passport number

Country Of Issue

Cell

Tel (H)

Postal Address

Physical Address

Village/Town

Occupation

Basic Salary P

Employee Number

Tel (W)

Fax

Date of commencement of employment

Name of previous Medical Schemes

Date of joining the Fund

Date of previous membership From:

Date of previous membership To:

Membership Number

Terms & Conditions
By signing this membership application form, you agree that Pulamed/AFA may collect, use and disclose your personal data, as provided in this application form, or obtained by Pulamed/AFA as a result of your membership, in accordance with the Data Protection Act of 2018, for the following purposes : (a) the processing of this membership application; and (b) the administration of the membership with Pulamed. Please note that you can withdraw your consent to the collection, use or disclosure of your personal data at anytime.