ROCKET Connect

ROCKET Connect

Application form
This application is subject to the ROCKET Connect Master Terms and Conditions applicable to the ROCKET Connect Service. By completing this application, you confirm that you have read, understood and agree to be bound by the Master Terms and Conditions, and you warrant that the Information you provide herein is true and correct. Please contact ROCKET HEMS on 0860-FLIGHT (0860 354 448) if you require more information regarding the application process, or visit our website.
Title*
First NameLast Name
Id/passport number - complete*
Contact Number*
Please enter a valid phone number.
Email Address*
example@example.com
Street Address

Line 2

CityProvince

Postal Code
Postal Address
MEDICAL AID DETAILS

MAIN APPLICANT
Medical aid name

Member number

Main member
We reserve the right to claim any of our incurred expenses in executing the required services from your Medical Aid, and you undertake to assist us in this regard. Should the Medical Aid reject the claim, there will be no additional cost to the client.

DEPENDENT DETAILS

PLEASE ENSURE THAT EACH MEMBER THAT WISHES TO UTILISE THE PANIC APP, INCLUDES A SEPERATE EMAIL ADDRESS. NO TWO MEMBERS CAN MAKE USE OF THE SAME EMAIL ADDRESS. ALL MEMBERS MUST SUPPLY A FULL ID NUMBER.
Dependent 1
First Name   Last Name

Id/passport

Phone Number

Email

Medical aid name

Medical aid number
Dependent 2
First Name   Last Name

Id/passport

Phone Number

Email

Medical aid name

Medical aid number
Dependent 3
First Name   Last Name

Id/passport

Phone Number

Email

Medical aid name

Medical aid number
Dependent 4
First Name   Last Name

Id/passport

Phone Number

Email

Medical aid name

Medical aid number
Dependent 5
First Name   Last Name

Id/passport

Phone Number

Email

Medical aid name

Medical aid number
Dependent 6
First Name   Last Name

Id/passport

Phone Number

Email

Medical aid name

Medical aid number
Dependent 7
First Name   Last Name

Id/passport

Phone Number

Email

Medical aid name

Medical aid number
Dependent 8
First Name   Last Name

Id/passport

Phone Number

Email

Medical aid name

Medical aid number
Dependent 9
First Name   Last Name

Id/passport

Phone Number

Email

Medical aid name

Medical aid number
Dependent 10
First Name   Last Name

Id/passport

Phone Number

Email

Medical aid name

Medical aid number
CONFIRM YOUR MONTHLY FEE
NUMBER OF MEMBERS - INCLUDING MAIN MEMBER
R75.00 PER MEMBER / PER MONTH / MINIMUM 12 MONTHS
FEE PER MONTH
CUSTOMER BANKING DETAILS

DEBIT ORDER AUTHORISATION
BANK:   ACCOUNT NO:

BRANCH NAME:   BRANCH CODE:
ACCOUNT TYPE

CURRENTSAVINGS

OPTIONAL - FIRST AID KIT PHYSICAL DELIVERY ADDRESS
I WOULD LIKE TO PURCHASE A FIRST AID KIT AT R1500 ONCE OFF:

YESNO
Street Address: City: Province: Code:
PAYMENT AUTHORISATION

PAYABLE TO BRISK SOLUTIONS
Please choose when your solution must be activated

Please activate with prorate asapPlease activate on the 1st of the new month
I AGREE TO MY ACCOUNT (WITH DETAILS AS SPECIFIED ABOVE) BEING DEBITED IN FAVOUR OF BRISK SOLUTIONS (PTY) LTD (T/A ROCKET HEMS) ON THE FIRST BUSINESS DAY OF EACH MONTH FOR THE DURATION OF THE SUBSCRIPTION PERIOD. I AM THE PERSON WHO AUTHORISES PAYMENTS FROM THIS ACCOUNT, AND MY DETAILS ARE:
First Name*

Date* Signature*
DECLARATION

ROCKET HEMS cares about you and your loved ones.Please familiarise yourself with the ROCKET Connect Service and the detailed Master Terms and Conditions that are also available on our website, as they contain important information. Please visit our website to read our Privacy Notice and see how we comply with the Protection Of Personal Information Act (POPIA). This includes what we collect in terms of personal information, why we collect it, how we collect it and what it is used for (“Privacy Policy”). By using/subscribing to our services and/or our Website and/or our ROCKET Connect Mobile App, you agree to the terms set out in the Privacy Policy. You agree that we may process your personal information for, amongst other things, (i) the purposes of providing you with access to our Products/Services, our Website and/or our ROCKET Connect Mobile App; and (ii) for any other purposes set out in the Privacy Policy.Your contract is effective from the date the first payment has been received. Your monthly subscription will be paid in advance and your first payment will be calculated on a pro rata basis from date of activation AND first payment. If the payment day falls on a Sunday or public holiday, the payment day will be the next business day. Should you have insufficient funds in your account for the debit order amount, ROCKET HEMS may attempt to debit your account as soon as sufficient funds become available. Brisk Solutions t/a ROCKET HEMS name and account number will reflect on your bank statement as reference of payment. You may cancel this debit order authority, but it will not result in cancellation of the contract.If an amount was legally owing to ROCKET HEMS, you will not be entitled to a refund while this debit order authority was in force. Your ROCKET Connect Services will be suspended if you have any outstanding payments due and your account may be assigned to an external debt collecting agency. We will not allow any person to make changes to your ROCKET HEMS account unless we have written authority from you to do so. It is important that you read and understand the ROCKET HEMS Master Terms and Conditions which you will also find on the ROCKET HEMS website.By signing the below, you acknowledge that you understand and agree to this declaration.
First Name*

Date* Signature*
Please select your ambassador*
Please select the ambassador that reffered you to ROCKET Connect
Should be Empty:

MEDICAL AID DETAILS

DEPENDENT DETAILS

Dependent 1

Dependent 2

Dependent 3

Dependent 4

Dependent 5

Dependent 6

Dependent 7

Dependent 8

Dependent 9

Dependent 10

CONFIRM YOUR MONTHLY FEE

CUSTOMER BANKING DETAILS

OPTIONAL - FIRST AID KIT PHYSICAL DELIVERY ADDRESS

PAYMENT AUTHORISATION

DECLARATION