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(A United Methodist e lns
CA 'S FUT
INVESTING IN AFRI
URE
'). RO1i 9
Student Number

RIC
R EXEMPTION FROM JOINING THE AF UNIVERSITY MEDICAL AI
D
APPLICATION FO A
SCHEME

1. Personal details
a) Name
w1 LL I AMS A-l: LbTH A KOP AfA~;zo
li!Ad&[ es~ C,{AOI
QJ~
epartment Gs s f
b) College/D

Cell Number +~63f<il';l~ 11-0f O

n
of Parents/Guardia
2. Personal Details ·
aj Name At VI NE l
WI U..1 AMS KI\U--lE~ H
b) Work place T'b- bl t4 MO ~t) Ll)M PA N~ (;zc ~c)
f-l.A
Z1iU~Af> \rJ°fu (,OJ'.\PO E-m ail ho .;vy,ro.CX) tl e ~g V\QO.c,o'Wt
c) Cell Number ±l
'2~1:t2..~'bi } b'- _ _ Home · 1,
...,____ _
. ,_ 1-'/A
k) _ .N-
d) Telephone (Wor

Student do
3. Declaration By Y\O PA fA ~t.O
a) I W
lf
LD A
ILLIAM S £ exempted from joining the Africa University Medica embership
l Aid
hereby apply that I
be e my m
mem ber of Fi i< -S1 MU]JALS cheme wher
ady a
Scheme as I am alre
number heme)
(Name of medical sc embership .)
ti -
02 . (Attach evidence of m
Is 13
5':2. ~ S"
ty for
sts incurred, wi
l_ ll pay cash to the Universi
does not pay the co
b) If the medical aid
all services rendered
Card
a valid Medical Aid
NB : Attach copy of
06 Novl M/QfR. ~0~3
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