Application Form: Member Details

This form is only used to become a BlueChip member. No product is selected or any billing performed until you have done so on the membership pages and faxed through your signed debit order form.

Be sure to read the product information page for details on the BlueChip product.

Please do not hesitate to contact us at any time on

Member Identification:
BlueChip Member Number: (As found on top-right of application form)  
RSA ID Number:
Passport Number:
Banking Details:
Bank Name:  
Branch Name:
Please select a bank
Don't know your branch code? Click here.
Branch Code:
e.g. 001234 (including 0, no lines or spaces, etc)
Account Name:
Account Type:
Account Number:
Only numbers, no spaces, lines, etc
Prefered Day of Debit: of the following month.

Please note that all fields are required.