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P
lease complete the form below and press send mail at bottom of page.
Please ePlease ensure all details supplied are correct. Elixir Shields or associated parties or persons cannot be held responsible for any ommisions and or mistakes supplied on this form. The data below will be captured exactly as supplied to us on this form.
Disc Number:
Mr
Mrs
Miss
Surname:
Full Name:
Email Address
Home Address
Postal Address
Date of Birth
ID Number
Contact Details:
Phone (Home)
Phone (Work)
Cell
E-Mail
Medical Aid / Hospital Plan:
Fund Name
Membership Number
Emergency Contacts
Primary Contact
Mr
Mrs
Miss
Phone (Home)
Phone (Work)
Cell
E-Mail
Second Contact
Mr
Mrs
Miss
Phone (Home)
Phone (Work)
Cell
E-Mail
Medical Details
Doctors Name
Contact Numbers
Surgery
Emergency
Cell
Blood Group
(If Known)
Medical Condition
Medicines -
Name and Dosage
Allergies - Please List
Todays Date
Emblem Order Form
Stainless Steel
Ladies Bracelet
0
1
2
3
4
5
6
7
8
R150.00 inc Vat & Postage
Gents Bracelet
0
1
2
3
4
5
6
7
8
R150.00 inc Vat & Postage
Neck Disc and Chain
0
1
2
3
4
5
6
7
8
R160.00 inc Vat & Postage
Ladies Diabetic Bracelet
0
1
2
3
4
5
6
7
8
R150.00 inc Vat & Postage
Gents Diabetic Bracelet
0
1
2
3
4
5
6
7
8
R150.00 inc Vat & Postage
Diabetic Neck Disc and Chain
0
1
2
3
4
5
6
7
8
R160.00 inc Vat & Postage
Sterling Silver
Ladies Bracelet
0
1
2
3
4
5
6
7
8
R390.00 inc Vat & Postage
Gents Bracelet
0
1
2
3
4
5
6
7
8
R390.00 inc Vat & Postage
Neck Disc and Chain
0
1
2
3
4
5
6
7
8
R410.00 inc Vat & Postage
Ladies Diabetic Bracelet
0
1
2
3
4
5
6
7
8
R390.00 inc Vat & Postage
Gents Diabetic Bracelet
0
1
2
3
4
5
6
7
8
R390.00 inc Vat & Postage
Diabetic Neck Disc and Chain
0
1
2
3
4
5
6
7
8
R410.00 inc Vat & Postage
9ct Gold
Ladies Bracelet
0
1
2
3
4
5
6
7
8
R2700.00 inc Vat & Postage
Gents Bracelet
0
1
2
3
4
5
6
7
8
R2700.00 inc Vat & Postage
Neck Disc and Chain
0
1
2
3
4
5
6
7
8
R2900.00 inc Vat & Postage
Ladies Diabetic Bracelet
0
1
2
3
4
5
6
7
8
R2700.00 inc Vat & Postage
Gents Diabetic Bracelet
0
1
2
3
4
5
6
7
8
R2700.00 inc Vat & Postage
Diabetic Neck Disc and Chain
0
1
2
3
4
5
6
7
8
R2900.00
inc Vat & Postage
Velcro Emergency
Bracelets
Ladies
0
1
2
3
4
5
6
7
8
R 170.00
inc Vat & Postage
Gents
0
1
2
3
4
5
6
7
8
R 170.00
inc Vat & Postage
Diabetic ladies
0
1
2
3
4
5
6
7
8
R 170.00
inc Vat & Postage
Diabetic ladies
0
1
2
3
4
5
6
7
8
R 170.00
inc Vat & Postage
Standard Package
Documax Package
Payment Details
Please note, no order will be processed before proof of payment is received. Payment must be made into the account detailed below and proof of payment must be faxed to 0860 103 684.
Bank Details
Account Name: ELIXIR BRACELETS
Bank: ABSA
Account Number: 4055 031 468
Branch Code: 510 829
ANNUAL SUBSCRIPTION
The MONTHLY/ANNUAL SUBSCRIPTION is payable ONLY from the SECOND YEAR of ownership. There is no charge for the first year. I,
Hereby authorise ELIXIR to draw against my/our account with the under mentioned bank (or any other bank or branch to which I/we may transfer my/our account) the sum of Standard Package R 60.00 (sixty rand) per year
Standard Package
Documax Package R 15.00 (fifteen rand) per month
Documax Package
. BEING PAYMENT OF MY
Monthly
ANNUAL SUBSCRIPTION ONLY COMMENCING IN MONTH.
The month in which you bought your bracelet) YEAR:
(Next year) and continuing until termination by me/us by giving you thirty days’ notice in writing.
In the event of an increase in this amount in excess of 10% per annum, I must be advised by ELIXIR, prior to such withdrawal. All such withdrawals from my/our bank account by you shall be treated as though they had been signed by me/us personally.
Due to Internet security reasons and bank detail theft on the internet Elixir will not require you to supply your banking details on this form. Elixir will contact you for your banking details telephonically on receipt of this application form.
Debit Order authorization
Send me a carbon copy of this email.