Membership Registration Form
Address: 270 Yorkland Boulevard, North York, ON M2J 5C9 Ph.: (647) 616-2599 Email: info@muslimcare.ca Website: www.muslimcare.ca
Application Type
*
New Application
Modification
Applicant Name
*
Gender
*
Male
Female
DATE OF BIRTH
*
-
Month
-
Day
Year
Date
MEMBER ADDRESS & CONTACT INFORMATION
APT/UNIT #
STREET NO. NAME
*
CITY
*
PROVINCE
*
POSTAL CODE
*
COUNTRY
*
CELL PHONE
*
HOME PHONE #
PRIMARY EMAIL
*
example@example.com
SECONDARY EMAIL
example@example.com
DEPENDENTS (spouse and children up to maximum of 25 years of age, living at the same address)
Full Name
Male
Female
DATE OF BIRTH
RELATIONSHIP TO MEMBER
1
2
3
4
5
6
BENEFICIARY DESIGNATION
PRIMARY BENEFICIARY'S ADDRESS & CONTACT INFORMATION
NAME
*
RELATIONSHIP TO THE APPLICANT
*
SPOUSE
Other
APT/UNIT #
STREET NO. NAME
*
CITY
*
POSTAL CODE
*
PROVINCE
*
PRIMARY EMAL
*
SECONDARY EMAIL
example@example.com
CELL PHONE #
*
HOME PHONE #
Please enter a valid phone number.
SECONDARY BENEFICIARYS ADDRESS & CONTACT INFORMATION
NAME
RELATIONSHIP TO THE PRLICANT
SPOUSE
Other
APT/UNIT #
STREET NO NAME
PROVINCE
CITY
POSTAL CODE
HOME PHONE #
Please enter a valid phone number.
CELL PHONE
PRIMARY EMAL
SECONDARY EMAIL
example@example.com
Membership and Authorization Checklist
*
I agree with the Muslim CARE membership terms and conditions.
I authorize Muslim CARE to withdraw MAXIMUM C$20 for any DEATH occurs among Members' Family.
I agree to pay Muslim CARE C$150 non-refundable one-time membership fee.
I understand that I am not automatically accepted into a membership by completing this registration form. The registration will become active once the fee payment has been withdrawn from the bank account while I as the main applicant is still alive. Upon completion, the applicant will be provided a confirmation notification with a membership number assigned.
I understand it is my responsibility as a member to inform Muslim CARE of any changes in the above information (Banking / Address / Phone # / Family Situation) IMMEDIATELY.
I understand it is the responsibility of the member for additional charges if payment results in NSF charges incurred by Muslim CARE.
I agree to allow Muslim CARE to send emails related to the administration and marketing of this membership.
I also understand that a sum of C$6,000 will be provided to my Beneficiary at the time of my or my dependent's death to cover the funeral cost.
I understand and agree that all the information provided on this form is true, accurate and binding, and dependents and beneficiaries listed above ONLY will be considered eligible if their official ID's match with the information provided, while disbursing C$6,000 in the event of Death.
After clicking "Submit," you'll be redirected to the Muslim Care direct debit authentication form. Please complete it by just providing your name.
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