APPLE DENTAL ENROLLMENT FORM

Non Member (Payer) * Requiered

*Name *Last

*Date of Birth

* Address

* City *State

* Zip

* Email

*Phone

Home Phone:
Cell/Alternate Phone:

Additional Members:	Relationship	Date of Birth

Payment Options:

I would like to pay the entire annual premium plus the first year enrollment fee with my application.

I would like to have my credit card or checking account debited monthly. (DO NOT CHECK BOX IF PAYING ANNUALLY). It's my choice to make first year monthly payments on the 1th of each month.

Payment Schedule:

Plan: Individual. Inicial Payment (First 2 months) $25.90 Monthly Cost: $12.95.

Plan: Individual. Annual Payment $129.50. (2 Months Free)

Plan: Family. Inicial Payment (First 2 months) $29.90 Monthly Cost: $14.95.

Plan: Family. Annual Payment 149.50 (2 Months Free)

Your Credit Card Statement will read: DDSI-APPLE DENTAL
AMERICAN EXPRESS       DISCOVER        MASTERCARD        VISA

NAME ON THE ACCOUNT
            CREDIT CARD NO.
            EXPIRATION DATE
              CUSTOMER CODE

Please allow 20-30 days to receive Permanent Membership Card(s).
***** Pay to the order of DDSI-APPLE DENTAL *****
Include Initial Payment or Annual Payment
PLUS $30.00 ENROLLMENT FEE

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