Please read the following explanations before filling out your application forms:

1. Application Form* – soc 3008B – This form must be completed by the applicant and contains all the important information and details of the applicant/s (compulsory to complete).
   
   
2. Medical Certificate* – soc 3016 – This forms needs to be completed by a Medical Practitioner or District Surgeon. It contains all the relevant Health Care details of the applicant (compulsory to complete).
   
   
3. Acknowledgement of Debt*– soc 3012 – This form must be completed by the applicant and is an acknowledgement that all debts incurred by the CPOA during the period of stay in a CPOA facility may be recovered from the applicant or the applicant’s estate upon death (compulsory to complete).
   
   
4. Deed of Suretyship – soc 3011 – This form is completed and authorized by a third party to confirm that any due payments, incurred by the applicant, will be paid on behalf of the applicant (not compulsory).
   
   
5. Debit Order Instruction Form – soc 3024 – This form is completed as an instruction to the applicant’s financial institution of choice to recover any due payments each month by debit order (not compulsory).
   
   
6. Annexure A (Undertaking by the Applicant) – soc 3008B – This document is retained by the applicant and forms part of the Application as an annexure.
   
   
7. Annexure B* (Statement of Income and Expenditure) – soc 3017 – This form must be completed by the applicant and is a summary of the applicants monthly income and expenses (compulsory to complete).  

All these documents must be present to constitute a “Complete Application” even though they do not all have to be completed.

* The Application Form,  Acknowledgement of Debt, Annexure B and the Medical Certificate are compulsory documents to complete.

Once this has been completed it may be submitted to the Social Work Department at CPOA Head Office.

FAX: 021 685 6689

Email: info@cpoa.org.za