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of debt
I, the undersigned, (main member’s full first 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:

2. I/my dependent,

, have applied for an advance supply of authorised chronic medicine.

3. 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.
4. 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 beneficiary.
5. I choose as domicilium et executandi for all purposes hereof, the following physical address:


6. I hereby consent to the jurisdiction of the Magistrate’s Court of South Africa having jurisdiction over me in
connection with all legal proceedin