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   The Golden Harvest Savings Plan

Member Enrollment Form
 
 
First Name: * Age:
Surname: * Gender: Male Female
Street: *  
City:  
Country: Designated Beneficiary:
Telephone: Relationship:
Date of Birth:
 
 
Golden Harvest Savings Plan Contract

( Enter an amount in either "Savings Goal" or "Monthly Deposit Required" ) 
Savings Goal: Term:  
(Between 12 to 120 months only)
Monthly Deposit Required:    
 
Within the last five years have you ever been treated for or been advised that you have any of the following conditions: diabetes, heart disorders, any cancer, acquire immune deficiency syndrome (AIDS), HIV infection or AIDS related complex? Yes No

 
 
 
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