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ATLANTIC FUNERAL SERVICES

WESTERN CAPE

APPLICATION FORM

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Standard Plans

Society Plans

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

Pay@

Debit Order

Terms and Conditions *

Yes

No

Declaration & Consent*

Yes

No

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*Please read the 'Terms and Conditions' and the 'Declaration and Consent' sections. By reading these and submitting you give your consent, this is your signature.

*Policy Packages can be viewed on 'Our Services' page

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

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