I CARE NETWORK

I CARE NETWORK SHAREHOLDER APPLICATION FORM

Name^*

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Personal Information

Title^*

Initials^*

Surname^*

First name^*

Citizenship^*:

South African citizen

Non-SA citizen

ID number^* Valid SA ID number has 13 digits

Gender^*

Race (optional)

Personal Postal Address

Postal address^*

City / Town^*

Province^*

Country^*

Postal code^*

Personal Physical Address

Physical address^*

City / Town^*

Province^*

Country^*

Postal code^*

Contact Information

Work telephone^*

Fax

Mobile number^*

Private e-mail^*

Work e-mail^*

PRACTITIONER OR HOSPITAL APPLICATION

Please indicate whether your application is for a practitioner or a hospital

Practitioner

Hospital

Additional information

Any additional information regarding the application

I hereby apply to take up shares in the I CARE NETWORK (RF) (PTY) LTD (the Company), the objects of which are to negotiate with the funders of health care, managed care organisations, other health care providers and the suppliers of goods and services to the respective shareholders of the Company, with a view to maximising the potential synergistic and rationalisation benefits for each shareholder. I acknowledge that the Memorandum of Incorporation of the Company is available for my inspection.

I agree and understand.

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I CARE NETWORK SHAREHOLDER APPLICATION FORM

Personal Information

PRACTITIONER OR HOSPITAL APPLICATION

Practice Information

Hospital Information

Additional information