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

By click Sumit you agreed to the terms and conditions.

APPLICATION - AUTHORIZATION:
I wish to become a member of APPLE DENTAL and understand my membership is on an annual basis and that i can terminate it on any anniversary date of my initial enrollment. It is my understanding i have to option of paying for the membership on an annual or monthly basis. The latter will include two monthly payments plus $30.00 enrollment fee. (FIRST YEAR ONLY) For monthly membership payment, I authorize the company to initiate debit entries to my (our) checking account or credit card. I understand it is the responsibility of APPLE DENTAL and myself to keep my membership in force. To guarantee uninterrupted service I approve of the Company's automatic monthly renewal of my membership upon expiration. this authority shall remain in effect until revoked by me in writing. i reserve the right to pay for membership on an annual basis if i desire. By accepting the plan, I am accepting the terms of this application and permission to be called by the company's computers.