(1) I, the undersigned, hereby make application to be amnitted as a member of SAMWUMED (the Scheme) and if amnitted, I ~ to abide by the Rules of the Scheme. I understand that confirmation of acceptance of membership is subject to the approval by the Scheme. (2) I declare that my answers and the information St4)1)1ied by me in this application, whether in my own handwriting or not, are true, correct and complete. (3) I understand that should this application contain any false statement or fail to disclose any material infonnation, the Board of Trustees of the Scheme (“the Board”) may, in terms of section 29(2)(e) of the Mecical Schemes Act 131 of 1998, regard my membership of the Scheme void ab i’litio (as if it never cormienc:ed). I understand that should the Board terminate my membership on this basis, the following shal apply: (a) I will be riable for inmediate repayment to the Scheme all benefits received by or on behalf of me; and (b) All or part of the contributions paid by me to the Scheme may be retained by the Scheme to offset any costs which the Scheme has ilcurred on my behalf; (c) The Rules of the Scheme will not be applicable to me and I will have no right of recourse against the Scheme in terms the Rues. (4) I hereby authorise my en1)loyer to deduct, from my salary/wages, any amourt(s) owed to SAMWUMED and remit such amourts to the Scheme on my behalf. I confirm that I am iitinately responsible for ensuritg my contri:>Uion is received by the Scheme each month. (5) I confirm that I understand and am familiar with the benefits of the Option I have selected. (6) I authorise my healthcare provider or any other party who may be in possession of i’lformation concerning my or my dependant’s health to disclose such information to SAMMJMED and its business partners, provided that such i’lformation shall be kept confidential at all tines. Such confidential health and personal information will only be used for purposes as outined in this form. (7) I undertake to inform the Scheme within 30 days of any changes in my or my dependant/s health or personal status as required by the Scheme Rues. (8) I undertake to notify the Scheme in accordance with the Rules of the Scheme shoud I wish to terminate my membership. (9) I consent to the recording of all conversations between myself and the Scheme or its contracted business partners.