Employer Sign-up

This serves as an application for an employer to enroll in:

1. The mediBucks value-add healthcare provider access and services platforms for employees
2. The medibucks payment platform for deposits by way of single monthly EFT deposits towards multiple employees mediBucks savings accounts as per monthly employer generated contribution schedules.

Employer Details

Untitled

Registered Name

Registration number

VAT number (if applicable)

Industry

Untitled

Postal Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Physical Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Contact Person for Contributions

Name

First Last

Phone

Contact Person for Employee Data

Name

First Last

Phone

Commencement Date

Employee Main Accounts only

Employee Main Accounts with separate dependent wallets

Employee main mediBucks account

Monthly savings account contribution towards employee and dependent wallets

Other Amount

Employee dependent linked-savings wallet

Monthly savings account contribution towards employee and dependent wallets

Other Amount

Number of employee main mediBucks cards required

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Name

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