MEMBERSHIP enrollment FORM

¨ New Enrollee ¨ Change in Enrollment ¨ Renewal

SECTION I: PLEASE PRINT Name:___________________________________________ Address:_________________________________________ _________________________________________________ E mail:_________________________________ Home Phone #:____________________________________ Work Phone #: _________________________ Martial Status: ¨ Single ¨ Married ¨ Divorced ¨ Widowed ¨ Legally separated
SECTION II: Identify dependents you are including in your Plan Option.
LAST	FIRST	MI.	RELATIONSHIP	BIRTHDAY MTH DAY YR	SEX M/F
MEMBER			SELF			XXXXXXXXXX
DEPENDENT						XXXXXXXXXX
DEPENDENT						XXXXXXXXXX
DEPENDENT						XXXXXXXXXX
DEPENDENT						XXXXXXXXXX
DEPENDENT						XXXXXXXXXX

SECTION III: PLAN OPTION SELECTION - YOU MUST CHOOSE A PLAN - CHECK ONE BOX ONLY.

	M Monthly* Credit Card Only	Quarterly* Credit Card Only	Annual Credit Card, Check, Money Order
Single	¨ $4.50	¨ $12.95	¨ $45.95
Married	¨ $4.95	¨ $13.95	¨ $49.95
Family y	¨ $4.95	¨ $13.95	¨ $49.95

* Important - Monthly and Quarterly payment can only be made with a credit or debit card.

SECTION IV: Payment Information

¨ Check or money order (according to section III) $__________ (Check or money order can only be for Annual membership)

¨ Credit Card: ¨ VISA ¨ MasterCard ¨ AMEX ¨ Discover

Card number # ______________________________________ Expiration Date: _____/____

Name of Card Holder: __________________________ Signature: ______________________________

I understand that the credit card listed above will be charged according to the frequency of payment I elected.

Fax or mail the completed form to: RxDrugCard.Com

P. O. Box 1849

Coppell, TX 75019

Phone: 888-216-2461 Fax: 425-696-0901