Optometrist Corner

	Pre Requisites
	Forms
	Find a Member
	Share Holding
	Fees
	Nimas
	Medical Tariffs
	Medical Schemes
	Journal Room
	Events to Attend
	Vision Partners
	CPD

Application for Shares

<< back

Iso Leso Optics Limited

Iso Leso Optics Limited

APPLICATION TO SUBSCRIBE FOR SHARES

I/We the undersigned, the owner/s of the optometry business practice which I/we carry on under the name and style of ______________________________________________________________
hereby apply to take up ________ (number) shares in Iso Leso Optics Limited (the Company) (or such other name as may be approved by the Registrar of Companies) the objects of which are to negotiate with the funders of health care, managed care organisations, other health care providers and the suppliers of goods and services to the respective shareholders of the Company with a view to maximising the potential synergistic and rationalisation benefits for each shareholder. I/We acknowledge that the Articles of Association of the Company are available for my/our inspection and consider myself/ourselves bound to the terms and conditions thereof.

Attached find a cheque in the amount of R___________ being the purchase price of __________shares.

	Insert name/s of owner/s of practice	No of shares
Signature	Name
Signature	Name
Signature	Name
Signature	Name
Signature	Name
Signature	Name

Note

Refer page 5 for cost and number of shares
Make cheque payable to Iso Leso Optics
Iso Leso Bank details for share capital only:
ABSA Bank Northcliff
Account number: 4051241013
Branch code: 632005
Please fax deposit slip to 011 888 8857

(Shareholder's information)

Please forward completed information to:
Iso Leso Optics Limited, P O Box 2127, Cresta 2118, or Telephone: (011) 888 4681, Fax: (011) 888 8857,
E-Mail address: healthman@medmall.co.za

CONFIDENTIAL

A. PRACTICE DETAILS (Please complete in respect of each practice site to be registered)
MV

PRACTICE NAME
PHYSICAL ADDRESS OF PRACTICE	Postal code:
POSTAL ADDRESS OF PRACTICE	Postal code:
PRACTICE NUMBER	070 000
PRACTICE TELEPHONE NO.	( )
PRACTICE FAX NO.	( )
CELL NO FOR OPTOMETRIST.	( )
E-MAIL ADDRESS
NAMES OF OWNER/S OF PRACTICE (Full details to be provided under paragraph B)	____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________
Practice management software (e.g. MASS, Medsolve, Optimax, etc.)

BANK DETAILS

ACCOUNT HOLDER'S NAME
BANK AND BRANCH
ACCOUNT NUMBER
BRANCH CODE

B.1 PERSONAL DETAILS (Complete in respect of each proposed shareholder)

TITLE
SURNAME
FIRST NAMES
POSTAL ADDRESS
HPCSA REG. NUMBER (old SAMDC)
IDENTITY NUMBER
ARE YOU A MEMBER OF AN IPA, NETWORK OF OPTOMETRISTS, OR A FRANCHISE? If so, please state name
ARE YOU A PAID UP MEMBER OF SAOA?	YES / NO
EDUCATIONAL INSTITUTE AT WHICH YOU QUALIFIED
NUMBER OF SHARES APPLIED FOR

2nd OWNER

B.2 PERSONAL DETAILS (complete if there is more than 1 owner)

TITLE
SURNAME
FIRST NAMES
Postal Address
HPCSA REG. NUMBER (old SAMDC)
IDENTITY NUMBER
ARE YOU A MEMBER OF AN IPA, NETWORK OF OPTOMETRISTS, OR A FRANCHISE? If so, please state name
ARE YOU A PAID UP MEMBER OF SAOA?	YES / NO
EDUCATIONAL INSTITUTE AT WHICH YOU QUALIFIED
NUMBER OF SHARES APPLIED FOR

Iso Leso Optics Limited

P O Box 2127, Cresta, 2118
Tel: (011) 888 4681, Fax: (011) 888 8857

ACB AUTHORITY

You are hereby authorised to raise monthly debits to my bank account detailed below: SAVINGS:

NAME OF ACCOUNT HOLDER	____________________________________________________
PRACTICE NO.	____________________________________________________
BANK DETAILS	____________________________________________________
TYPE OF ACCOUNT :	CURRENT: ___________________
	SAVINGS: ___________________
NAME OF BANK	____________________________________________________
BRANCH	____________________________________________________
ACCOUNT NO.	____________________________________________________
BANK CLEARING CODE (top right corner of cheque)	____________________________________________________
AMOUNT TO BE CHARGED MONTHLY FROM: (R285.00 - VAT incl. per practice site / franchise site)	____________________________________________________

The company will charge my account on the 1st (first) and on the same day of each month thereafter. It is hereby agreed that this authority will remain in force until cancelled in writing.

SIGNED AT__________________________ on __________________________2008.

____________________________________________
Signature

PLEASE ATTACH A CANCELLED CHEQUE AND A COPY OF YOUR ID.

SHARE COSTS AND MANAGEMENT FEES

PRACTICE SITE	SHARE PREMIUM	VOTING SHARES AT PAR VALUE	MONTHLY SUBS
1 Practice 1 Owner	R1490	R10 share capital 10 Shares 10 Votes	R250 (excl. VAT) Per Practice
1 Practice 2 Owners	R1490	R10 share capital 10 Shares 5 Shares per Owner 10 Votes	R250 (excl. VAT) Per Practice
1 Practice 4 Owners	R1490	R10 share capital 10 Shares 1 x 4 Votes 3 x 2 Votes 10 Votes	R250 (excl. VAT) Per Practice
2 Practices 1 Owner	2 x R1490 R2980	R20 share capital 20 Shares 20 Votes	R250 per Practice R500 (excl. VAT)
2 Practices 4 Owners	2 x R1490 R2980	R20 share capital 20 Shares 5 Shares per Owner 20 Votes	R250 per Practice R500 (excl. VAT)
4 Practices 3 Owners	4 x R1490 R5960	R40 share capital 40 shares 14 Shares x 1 Owner 13 Shares x 2 Owners 40 Votes	R250 per Practice R1000 (excl. VAT)
1 Franchise 1 Owner	R1490	R10 share capital 10 Shares 10 Votes	R250 (excl. VAT) Per Franchise Site
1 Franchise 2 Owners	R1490	R10 share capital 10 Shares 5 Shares per Owner 10 Votes	R250 (excl. VAT) Per Franchise Site
2 Franchises 4 Owners	2 x R1490 R2980	R20 share capital 20 Shares 5 Shares per Owner 20 Votes	R250 per Practice R500 (excl. VAT) Per Franchise Site

NOTES:

Each site pays R1500 for 10 shares
Each site gets 10 shares at R10 par, plus R1490 share premium
Maximum shares per site - 10 shares
Owners of a practice can decide on number of shares to be held by individuals
Maximum shares per individual - 40 (depends on how many sites the individual owns alone) for multiple sites
A "site" shall mean a practice site or franchise site
An "owner" shall mean the optometrist who owns the practice
In the case of franchises, the owner shall be the franchisee


Click on the print button to print this form

When applying for membership with Iso Leso management services you will be required to complete the ACB Authority form.

Last Updated: 10 Mar 2011