Application Form Section A: Applicant - Your details (Please complete all boxes in BLOCK CAPITALS) * Applicant's personal details First Name Last Name Date of birth: * MM DD YYYY Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Email * Section B: Nominee’s details (Please complete all boxes in BLOCK CAPITALS) * Nominee’s personal details First Name Last Name Date of birth: * MM DD YYYY Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### Email Relationship to applicant: Section C: Select your funeral membership fund plan * Option 1 (Basic), Option 2 (Standard) and Option 3 (Comprehensive) Option 1 - Basic Option 2 - Standard Option 3 - Comprehensive Section D: Your declaration * I hereby apply to purchase a funeral membership fund plan for the arrangements I have selected. I acknowledge that the Provision4Peace funeral membership fund plan services will only be provided upon full payment of the plan's cost and will be subject to the terms and conditions of the Provision4Peace funeral membership fund plan. I understand that if I cancel the plan within 28 days, I will receive a full refund with no cancellation fees. However, if I cancel after 28 days, no refund will be issued. I accept that my funeral membership fund plan certificate will be issued within 28 days of full or final payment. Please note: The signature below must be of the person applying for and paying for the plan. Any refund due to cancellation will be returned to the applicant. Please ensure you sign in the box below to validate your application. I accept Thank you!
