Membership Registration Form Address: 270 Yorkland Boulevard, North York, ON M2J 5C9 Ph.: (647) 616-2599 Email: [email protected] Website: www.muslimcare.ca Application Type*New ApplicationModification Applicant Name* Gender*MaleFemale DATE OF BIRTH*Date MEMBER ADDRESS & CONTACT INFORMATION APT/UNIT # STREET NO. NAME* CITY* PROVINCE* POSTAL CODE* COUNTRY* CELL PHONE* HOME PHONE # PRIMARY EMAIL*[email protected] SECONDARY EMAIL[email protected] 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*SPOUSEOther APT/UNIT # STREET NO. NAME* CITY* POSTAL CODE* PROVINCE* PRIMARY EMAL* SECONDARY EMAIL[email protected] CELL PHONE #* HOME PHONE #Please enter a valid phone number. SECONDARY BENEFICIARYS ADDRESS & CONTACT INFORMATION NAME RELATIONSHIP TO THE PRLICANTSPOUSEOther APT/UNIT # STREET NO NAME PROVINCE CITY POSTAL CODE HOME PHONE #Please enter a valid phone number. CELL PHONE PRIMARY EMAL SECONDARY EMAIL[email protected] 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 The registration will become active once the fee payment has been withdrawn from the bank account while I as the main applicant is still alive.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. Preview PDF SaveSubmit Back to FormMUSLIMCARE MEMBERSHIP REGISTRATION FORM MUSLIMCARE MEMBERSHIP REGISTRATION FORM START FILLING
