MediCoop Finance Application

If you are a healthcare professional, healthcare worker or medical industry stakeholder and comply with the minimum requirements, you can either complete our credit application form below (online application process) or you can follow our manual application process by downloading our Credit Application Form using the link provided.

Credit Application MediCoop terms & conditions Accident cover terms & conditions

Application Type

* South African Citizen / Entity

* Apply as Individual or Business

* Business Type

Individual or Company Information

* ID Number

Business Reg Number

Business Name

* Title

* Initials

* Full Name(s)

* Surname

Nickname

* Marital Status

Spouse Name

Spouse ID Number

Spouse Contact Number

* Cellphone

Telephone

* Email Address

* Gender

* Race

Date Of Birth

Physical Address

* Line 1

Line 2

* Suburb

* City/Town

* Postal Code

Postal Address

* Line 1

Line 2

* Suburb

* City/Town

* Postal Code

Work Address

Line 1

Line 2

Suburb

City/Town

Postal Code

HPCSA Number

Practice Number

Other Professional Body or Association Membership Number

Specify Professional Body or Association

Employer / Place of Work

Employer Contact Number

Primary Account Information

Name Of Bank

Branch Name

Branch Code

Account Number

Account Type

Date Opened

Business Information

* Nature of Business

Date Established

Latest Financials Available

Financial Year End Month

Annual Turnover or Net Asset Value

Auditor

Auditor Contact Number

Business Short-Term Insurer

Business Short-Term Insurer Contact Number

Medical Malpractice Insurer

Medical Malpractice Insurer Contact Number

Trade References

Name

Surname

Contact Number

Name

Surname

Contact Number

Name

Surname

Contact Number

Name

Surname

Contact Number

Name

Surname

Contact Number

Company / Business Shareholding

Shareholder 1

Name

Surname

ID Number

Share Percentage

Physical Address

Line 1

Line 2

Suburb

City/Town

Postal Code

Shareholder 2

Name

Surname

ID Number

Share Percentage

Physical Address

Line 1

Line 2

Suburb

City/Town

Postal Code

Shareholder 3

Name

Surname

ID Number

Share Percentage

Physical Address

Line 1

Line 2

Suburb

City/Town

Postal Code

Shareholder 4

Name

Surname

ID Number

Share Percentage

Physical Address

Line 1

Line 2

Suburb

City/Town

Postal Code

Shareholder 5

Name

Surname

ID Number

Share Percentage

Physical Address

Line 1

Line 2

Suburb

City/Town

Postal Code

Equipment / Finance Requirements

* Description of Equipment or Finance Required

Make of Equipment

Model Number

Dealer / Supplier Name

Dealer / Supplier Contact Number

* Model Condition

Model Year

* Finance Period

* Finance Value

Installation Address

Line 1

Line 2

Suburb

City/Town

Postal Code

Where did you hear about us?

* Discovery Media

Source

Consent

* I/We, the applicant(s) and the signatory(ies) hereof in my/our personal capacities, hereby:

Declare that to the best of my/our knowledge and belief, the particulars set out in this application are true and correct, and that no additional or relevant information was withheld.
I/we give consent to the process of personal information and allow SA Primary Medical Financial Co-Operative Limited ("MediCoop CFI") to communicate with/contact me regarding membership information, the affairs of MediCoop CFI, its products and services available to members in terms of the Protection of Personal Information Act 4 of 2013. I/we agree that MediCoop CFI can use your photograph(s) to check your identity and FICA information from the Department of Home Affairs (DHA) and at any other party to confirm any aspect or details of this application. I/we agree to the terms and conditions.
I/we consent to MediCoop CFI or its cessionary making enquiries about my/our credit record with any credit reference agency and any other party to confirm the details on this application. MediCoop CFI or its cessionary may also provide credit reference agencies with regular updates regarding how I/we manage my/our account, including my/our failure to meet agreed terms and conditions. I/we consent that credit reference agencies may, in turn, make the records and details available to other credit grantors. MediCoop CFI or its cessionary may also give this information to any person who in its opinion, needs it to carry out any of MediCoop CFI or its cessionary's rights or duties in terms of the contract or any law pertaining to the products I/we have requested.
I/we hereby give MediCoop CFI or its cessionary permission to carry out identity and fraud prevention checks on me/us and to share the information provided in this application with the South African Fraud Prevention Service.
I certify that the above details are true and correct.

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