Affordable Dental Plan USA - Member Enrollment




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\| WALKIN ENROLLMENT OFFICE LOCATIONS \| Pay by CreditCard Online \| Pay by CreditCard over the phone \| Have us call you \|

1.	Pay by credit card online

* All field names in RED are mandatory.
		Individual $74.99 Couple / Single Parent & Child $99.99 Family $149.99
First Name
Last Name
Date of birth		(mm/dd/yy)
Street Address
City
State
ZIP Code
Phone Number
Email Id if any
		Details on additional members for couple/family (if applicable)
Spouse First Name
Last Name
Date of birth		(mm/dd/yy)

Child First Name
Last Name
Date of birth		(mm/dd/yy)

Child First Name
Last Name
Date of birth		(mm/dd/yy)

CreditCard Type		Visa MasterCard Discover American Express
CreditCard Number
Expiration Date
Amount $
		Individual $74.99/Couple or Single Parent & Child $99.99/Family $149.99
		Terms & Conditions I Agree I Disagree

2.	Pay by Credit Card over the phone
Please call (888)303-0600 or Fax :(215)646-6369

3.	Have us call you

* All field names in RED are mandatory fields
First Name
Last Name
Date of birth		(mm/dd/yy)
Phone Number
Email Id if any
Best time/day to call you