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DENTAmax Plus |
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3012 19th Street, Suite B Metaire, Louisiana 70002 |
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1-888-659-PLUS(7587)
504-838-8400 Fax: 504-838-8403 |
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www.dentamaxplus.com |
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____________________________________________________________________________ |
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Date__________
Representative__________________________________________ |
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Name_________________________________________________________________ |
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Address_______________________________________________________________ |
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City___________________State____Zip________ Home Phone___________________ |
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Employer_________________________________ Work Phone___________________ |
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Social Security Number______________________ (Must be Included) |
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______________________________________________________________________________
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Also cover the following: Name
Sex
Age Card(Y/N) |
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Spouse________________________________|________|_________|___________ |
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Children/Dependents____________________|________|_________|___________ |
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______________________________________|________|_________|___________ |
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______________________________________|________|_________|___________ |
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______________________________________|________|_________|___________ |
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______________________________________|________|_________|___________ |
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______________________________________|________|_________|___________ |
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Membership Fees |
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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 |
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One Time Enrollment Fee $15.00 |
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| Two membership cards are issued per
membership at no charge. Additional cards are $2.50 each |
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______________________________________________________________________________
| 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 |
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__ Check |
__ Check |
__ Check |
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| 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 |
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| ______________________________________________________________________________ |
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| 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_______________________________________ |
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