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Personal Details

Title:

Surname:

Full Names:

ID:

Language:

Maritial Status:

Postal Address:

Postal Code:

Physical Address:

Code:

email:

Business Telelphone:

Home Telephone:

Cellular:

Family Details

	Name & Surname	ID Number	Date of Birth
Spouse / Partner
Child One
Child Two
Child Three
Child Four
Child Five

Membership and Monthly Fees

Membership Option:

Platinum R65

Gold R45

Banking Details

Account Type:

Cheque

Transmission

Savings

Account Holder:

Bank:

Branch:

Branch Code:

Account Number:

Frequency:

Monthly

Annually

Start Date:

Date of Deduction:

1	15	25
26	28	Last Day of Month

Terms:

1.I the undersigned hereby apply for membership in accordance with Legal iQ's terms and conditions.
2.The application form is completed in my presence and submitted by me.
3. I acknowledge that payment of membership fees on the due dates is my responsibility.
4. I warrant that all information given in this application form whether in my handwriting or not is true and complete.
5. I further acknowledge and authorise that Legal iQ and the parties with whom it has business agreements may request of each other access to my personal banking details.
6. I understand and accept the implications of this agreement and I accept that this application together with the terms and conditions of membership represent the agreement between myself and Legal iQ in respect of my membership of Legal iQ.