Apply for Membership – Curamus Association

MEMBERSHIP APPLICATION

Tel: 012 314 0185 | Cell: 0713589903 | Email: curamus1@gmail.com

Personal Information

Surname *

Full Names *

Force Number

ID Number

Residential Address

Contact Details

E-Mail *

Cellphone

Tel Work

Tel Home

Service

Arms of Service

Unit

Attestation Date

Years of Service

Rank or Title

Mustering

Highest Qualification

Disability

Nature of Disability

Date of Injury

Percentage Disability (%)

Medical Classification

Current Job Status

Description of Current Job (if applicable)

Current Income

Injury Details

How Did You Sustain Your Injury?

Was It An Injury On Duty?

Pension/VPA or NPO Number

Next of Kin Contact Details

Name

Relationship

E-Mail

Cellphone

Tel Work

Tel Home

Additional Information

Relevant Disability Equity Training (if applicable)

Are You A Member Of Any Veterans Organisation?

If Yes – Name The Organisation

Recreation/Sport Activities

Signature *

Please sign in the box below using your mouse or touch screen

(Please ensure your signature is clear and legible.)

Curamus Association