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Western Cape Application Form

ATLANTIC FUNERAL SERVICES

WESTERN CAPE

APPLICATION FORM

please complete THE FORM BELOW

Please select your packages

Free Text

Click here to see packages

Standard Plans*

Society Plans*

Free Text

New Western Cape Society Plan Packages

Basic Society Plan

Grocery Society Plan

Cremation Society Plan

Title*

Last Name*

First Name

ID number*

Date of Birth*

Copy of ID

Mobile number*

Home Telephone number

Home Address*

Marital Status*

Single

Married

Divorced

Widowed

Gender*

Female

Male

Other

Source of Funds*

Salary/Wages

Proceeds of business

Social Grant

Investment

Other

If other, please specify

Spouse Last Names

Spouse First Names

Spouse ID Number

Spouse Date of Birth

Spouse Cellphone Number

Copy of Spouse ID

Beneficiary*

Spouse

Child (over18)

Undertaker

Other

Specify Other Full Names

Beneficiary ID Number*

Date of Birth*

Copy of ID

Cellphone Number*

Number of Dependants

1. Full name & surname

ID Number

Date of Birth

Copy of ID

2. Full name & surname

ID Number

Date of Birth

Copy of ID

3. Full name & surname

ID Number

Date of Birth

Copy of ID

4. Full name & surname

ID Number

Date of Birth

Copy of ID

5. Full name & surname

ID Number

Date of Birth

Copy of ID

6. Full name & surname

ID Number

Date of Birth

Copy of ID

7. Full name & surname

ID Number

Date of Birth

Copy of ID

8. Full name & surname

ID Number

Date of Birth

Copy of ID

9. Full name & surname

ID Number

Date of Birth

Copy of ID

10. Full name & surname

ID Number

Date of Birth

Copy of ID

11. Full name & surname

ID Number

Date of Birth

Copy of ID

12. Full name & surname

ID Number

Date of Birth

Copy of ID

13. Full name & surname

ID Number

Date of Birth

Copy of ID

Agent referred

Agent referred Telephone number

Payment Method 1*

Pay@ (this works directly with your policy number)

Payment Method 2*

Debit Order

Free Text

Debit Order Mandate

Terms, Conditions & Declaration

Terms, Conditions & Declaration

By reading these and submitting your tick below, you give your consent. This serves as your signature.

Terms & Conditions *

Yes

No

Declaration & Consent*

Yes

No

Form declaration*

Have you selected your package at the top of the form. All compulsory fields are indicated with an *.

By checking this box, I declare that

the information provided is accurate and

agree to share my form responses.

Thank you for choosing Atlantic Funeral Services as your trusted Funeral Home.

Did you remember to choose your package?

Our team will call you as soon as your application form has been processed.

Oops, there was an error sending your message.
Please try again later.

We are a member of the SA Funeral Practitioners Association(SAFPA)

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062 980 6851

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