Join Life FM Family

New Membership

Please complete the application form or contact us directly:

+27 18 468 5524

+27 66 516 6917

Postal Address

64 c Ian St, Wilkoppies, Klerksdorp, 2571

New Member Details

ID Number(Required)

Title(Required)

Initials(Required)

First Name(Required)

Last Name(Required)

Work Number(Required)

Cell Number(Required)

Email(Required)

Postal Code(Required)

Postal Address(Required)

Banking Details

Consent(Required)

I authorize LifeFM and my bank named below to charge my account monthly/yearly on one of the below mentioned dates. This will remain in effect until I give written notice to cancel it

Type of Account(Required)

Ex: Savings

Account Number(Required)

Bank(Required)

Branch(Required)

Branch Code(Required)

Date of Deduction(Required)

Amount in Rands(Required)

Please enter a number greater than or equal to 100.

Monthly or Yearly(Required)

This field is for validation purposes and should be left unchanged.

New Membership

Please complete the application form or contact us directly:

Postal Address

New Member Details

Banking Details

ADDRESS