DISCOUNT DENTAL APPLICATION
  Fax application with Credit Card Information
  Directly to (504) 885-4640
   
  ____________________________________________________________________________
  Date__________     Representative___Neil Williamson___________________________
  Name_________________________________________________________________
  Address_______________________________________________________________
  City___________________State____Zip________ Home Phone___________________
  Employer_________________________________ Work Phone___________________
  Social Security Number______________________ (Must be Included)
   
______________________________________________________________________________
  Also cover the following:    Name                           Sex                Age        Card(Y/N)
  Spouse________________________________|________|_________|___________
  Children/Dependents.____________________|________|_________|___________
  ______________________________________|________|_________|___________
  ______________________________________|________|_________|___________
  ______________________________________|________|_________|___________
  ______________________________________|________|_________|___________
  ______________________________________|________|_________|___________
_______________________________________________________________________________
 

Membership Fees

 
  Single Member+one Member and Family
Monthly $6.00 $8.00 $10.00
Quarterly $18.00 $24.00 $30.00
Semi-Annual $30.00 $40.00 $50.00
Annual $60.00 $80.00 $100.00
    ADD--->

 A One Time Enrollment Fee of $15.00


Two membership cards are issued per membership at no charge. Additional cards are $2.50 each
______________________________________________________________________________
Payment Method: Please check one:
      Monthly     Quarterly    Semi-Annual      Annual
__  Bank Draft __  Bank Draft __  Bank Draft __  Bank Draft
__  Credit Card __  Credit Card __  Credit Card __  Credit Card (Best Buy)
  __  Check __  Check __  Check
______________________________________________________________________________
Credit Card Information Bank Draft Information
MasterCard or VISA (please circle one) Name of bank_______________________
Card Number________________________ Checking account#___________________
Expiration Date_______________________ Signature___________________________
Name on Card_______________________ My signature above authorizes you to draft my checking account payable to DENTAmax Plus. This authorization is to remain in effect until revoked by me in writing. Please attach check for first month fees
Signature   x_________________________
______________________________________________________________________________
Renewal Authorization (for Semi-Annual and Annual Memberships)
For my convenience I authorize you to charge my DENTAmax Plus membership fees by the payment method I authorized above 30 days prior to the renewal date of my membership.

Signature of Applicant_______________________________________