NAPTOSA Single Need Indemnity Form

MEMP Financial Services (Pty) Ltd
27 Mangold Street, Newton Park, Port Elizabeth, 6045, South Africa
P O Box 34053, Newton Park, Port Elizabeth, 6055
Tel: +27 (0)41 363-7333
Facsimile: +27 (0)86 723-4635
E-mail : NAPadmin@memp.co.za
Authorised Financial Services Provider
SINGLE NEED CLIENT ADVICE INDEMNITY
PLEASE READ AND SIGN THIS DECLARATION.
I, __________________________________________________ (client name), confirm that I have been
advised by ___________________________________ of ______________________________(FSP name)
that, as an authorized financial services provider, he/she must, prior to providing me with financial
advice and for the purposes of the advice, undertake reasonable steps to seek from me appropriate
and available information to conduct an analysis of my financial needs.
I confirm that I have DECLINED the offer of such an analysis and or have indicated a single need and/or
product and/or product supplier which I have identified myself. I have been duly and properly advised
of the implications of my actions and having considered same, I still wish to proceed with the
implementation of my choice.
SIGNATURE OF FINANCIAL ADVISOR
SIGNATURE OF CLIENT
DATE
DIRECTOR: RS IMMELMAN
ASSOCIATES: PERIX HEALTHCARE CONSULTANTS T/A MEMP HEALTHCARE CONSULTANTS EAST LONDON - EAST LONDON: FSP 8978