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Acknowledgement of Debt (South Africa, English)
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Acknowledgement of Debt
I, the undersigned, (main member’s full irst name/s and surname)
_________________________________________________________________________
hereby confirm and agree to the following:
1. I am a member of the Government Employees Medical Scheme (GEMS) with membership number:
_________________________________________________________________________
- I/my dependent, ___________________________________________________________, have applied for an advance supply of authorised chronic medicine.
- I/my dependent, ___________________________________________________________, will be travelling outside South Africa for __________ month/s in total and understand that if approved, the medicine will be authorised and delivered in three (3) monthly intervals.
- Should I/my dependent resign Scheme membership within the applicable three (3) month period, I will be liable for the balance of the cost of the medicine supplied for the period where I am/my dependent is not a registered beneiciary.
- I choose as domicilium et executandi for all purposes hereof, the following physical address: ___________________________________________________________, Code ___________.
- I hereby consent to the jurisdiction of the Magistrate’s Court of South Africa having jurisdiction over me in connection with all legal proceedings arising here from.
- I/my dependent, is responsible for timeously supplying the Scheme with a new prescription should the medicine change during the applicable three (3) month period.
Signed at _______________ on this ______ day of _______________ 20__.
Main member’s signature _______________ Date ____________
Witness _______________ Date ____________