Marital Status: (required)
Date of Birth (required)
Maiden Surname (if applicable)
Identity No. (required)
Your present Occupation
MISA MemberNUMSA memberNon-Union member
The person to whom the death benefit shall be paid in the event of my death.
I, the undersigned, solemnly declare that the above particulars are true and correct, and I agree to abide by all rules and regulations which are in force, or may be brought into force, from time to time.
Consent in terms of Act 4 of 2013 (Protection of Personal Information Act).
I hereby consent to MISA processing my personal information (as disclosed in this form), which includes my union membership information (if applicable), for purposes of the Motor Industry Sick, Accident and Maternity Pay Fund Agreement as well as the Rules issued in terms hereof.