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When Death Occurs

Registration Form

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Registration Form

You may also complete the MuslimCare Membership Registration Form by downloading and printing this attached PDF.

Member Information

Full Legal Name *

Date of Birth *

Existing child member name *Applicants over 65 must have an offspring who is already an active member to ensure program sustainability.

Gender *MaleFemale

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Country *

Home Phone Number

Cell Phone Number *

Primary Email Address *

Secondary Email Address

You may also complete the MuslimCare Membership Registration Form by downloading and printing this attached PDF.

Dependents

SPOUSE AND CHILDREN ONLY (maximum 25 years old and must live at the same address)

Full Legal Name

Relationship to Member

Date of Birth

GenderMaleFemale

Full Legal Name

Relationship to Member

Date of Birth

GenderMaleFemale

Full Legal Name

Relationship to Member

Date of Birth

GenderMaleFemale

Full Legal Name

Relationship to Member

Date of Birth

GenderMaleFemale

Full Legal Name

Relationship to Member

Date of Birth

GenderMaleFemale

Full Legal Name

Relationship to Member

Date of Birth

GenderMaleFemale

You may also complete the MuslimCare Membership Registration Form by downloading and printing this attached PDF.

Beneficiary Designation

PRIMARY BENEFICIARY'S ADDRESS & CONTACT INFORMATION (other than the dependents age 18+)

Full Legal Name *

Relationship to the Applicant *

Home Phone Number

Cell Phone Number *

Primary Email Address *

You may also complete the MuslimCare Membership Registration Form by downloading and printing this attached PDF.

Payment Information

Bank Institute Name *

Branch Transit Number *

Institute Number *

Account Number *

Void Cheque *

No file chosen

Please attach a void cheque here.

You may also complete the MuslimCare Membership Registration Form by downloading and printing this attached PDF.

Membership and Authorization Checklist

*Please refer to Muslimcare Guidelines for the details and specifications

Rules and Regulations *

I agree with the MuslimCare membership rules and regulations.

Withdrawal *

I authorize MUSLIM CARE to withdraw Janaza Contribution* for every DEATH that occurs among Members’ Family up to a maximum of $20 CAD.

Registration Fee *

I agree to pay MUSLIM CARE one-time non-refundable membership registration fee* through automatic online Withdrawal.

Wait Period *

I understand that I am not automatically an active member by completing this registration form. My registration will be activated* and effective only after a confirmation notification and membership fee amount withdrawn from my bank account.

Information Update *

I understand it is my responsibility as a member to inform MUSLIM CARE of any changes in the information (Banking/Address/Phone#/Family situation/Designated Beneficiary) IMMEDIATELY.

Additional Charges *

I understand it is the responsibility of the member for additional charges if payment results in NSF charges incurred by MUSLIM CARE.

Membership Suspension *

I understand my membership shall be automatically SUSPENDED in view of 3 or more outstanding payment issues for Death/Janaza Contribution.

Email Updates *

I agree to allow MUSLIM CARE to send emails related to any updates and correspondences related to my membership.

Accurate Information *

I understand and agree that all the information provided on this form is true, accurate and binding, and dependents and beneficiary listed above ONLY will be considered eligible if their official ID’s match with the information provided, to facilitate us in issuing the entitled cheque in the event of Death.

Applicant's Signature *

Date *

Save as Draft

Muslim Care

270 Yorkland Blvd.
North York, ON, M2J5C9, Canada

Muslim CARE Hotline: +1 647-616-2599
info@muslimcare.ca

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