Join Us | Ashambe

Profile Information

Welcome! Thank you for joining As'hambe

Please complete the form to register. If you do not have some details, worry not, you can always submit those when available

Starting date

All fields marked with * are required and must be filled.

Effective date(Required)

Your Profile Information

All fields marked with * are required and must be filled.

Your Name(Required)

First Name Last Name

Email(Required)

Date of Birth(Required)

Phone Number(Required)

Form of Identification(Required)

RSA ID

Passport

Asylum

ID/ Passport/ Asylum Number(Required)

Please enter a number from 8 to 10.

Address

All fields marked with * are required and must be filled.

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Source

All fields marked with * are required and must be filled.

How did you hear about us?(Required)

Website / Online Search

Social Media

Referral

other

In case of Emergency, contact

Note: You can complete this later or change it at any time

Would you like to provide an emergency contact?

I will provide details later

I want to provide my details now

Emergency Contact Name

First Name

Last Name

Relationship

Phone Number

Select preferred plan

Note: You are welcome to add more dependents any time, up to 5

Plan selection

Member Only - Full benefit Passenger Assistance 191.80ZAR

Member + 1 - Full benefit Passenger Assistance 222.54ZAR

Member + 2 - Full benefit Passenger Assistance 253.29ZAR

Member + 3 - Full benefit Passenger Assistance 284.09ZAR

Member + 4 - Full benefit Passenger Assistance 314.78ZAR

Member + 5 - Full benefit Passenger Assistance 345.53ZAR

Members

Name

Surname

Date of Birth

Cell Number

Please input the details of your preferred members to cover in line with your plan selection, leave empty if its for yourself.

Payment mathod

All fields marked with * are required and must be filled.

I want to pay for my plan by(Required)

EFT

Debit Order

Debit order details

Row ID	Given by: Name of Account holder	Address	Bank	Account Number	Account type	Debit Date	Contact Number	Email	Plan Amount	To	Address	Abbreviated short name to be used is	Signed at	on date	Signature (as used for operating account)	Assisted by, if applicable	Capacity	Actions

There are no Entries.

Please us the details below for debit order

Account name: WEINIT BSG (Pty) Ltd

Bank: Nedbank

Branch Code: 198765

Account Number: 1269102788

Account Type: Cheque

Please use your ID/ Passport number as reference. Please email PoP to info@ashambe.africa

Signature

Signature(Required)