Cerenity Life Funeral Services – Membership Application

Package selection

	Package	Monthly fee	Includes
Select an age group and package type above to view available packages.

Main member details

First name

Surname

ID number

Date of birth

Gender

Nationality

Phone number

Email address

Physical address

Spouse details Optional

Spouse full name

Spouse ID number

Spouse date of birth

Children Optional — up to 4, under age 21

Child 1

Full name

Date of birth

ID / Birth cert no.

Beneficiary details

Beneficiary full name

Beneficiary date of birth

Beneficiary cell number

Payer details

Payer full name

Relationship to member

Bank name

Account number

Account type

Branch code

Debit order date

Debit order mandate

Selected package— Select a package above —

Age group—

Package type—

Waiting period—

Monthly membership feeR —

Total monthly debitR —

I/We hereby authorise Cerenity Life Funeral Services to issue and deliver payment instructions to your banker for collection against my/our account on the selected date, the amount necessary for payment of the monthly membership fee. This authority remains in force until cancelled in writing. I/We confirm that all information provided is true and correct and that the main member falls within the stated age group.

Digital signature

Please sign below to confirm agreement to the mandate and terms above.

Draw your signature here

✓ Application submitted successfully!