Member Application

Please enroll my household in the discount program initialed below:

Plan DC-MC at one-time processing fee of $25.00 and $24.95 per month_________

Plan DC-PH at one-time processing fee of $25.00 and $24.95 per month_________

Plan DC-GH at one-time processing fee of $25.00 and $24.95 per month_________

Plan DC-MC with Plan DC-PH at one-time processing fee of $40.00 and $44.95 per month_________

Plan DC-MC with Plan DC-GH at one-time processing fee of $40.00 and $44.95 per month_________

Plan DC-RX at $60.00 per year_________

 

Name __________________________________________________         Date _______________

Street Address __________________________________________________________________

City ______________________________________ State ________           Zip ___________

Phone (_____)___________________          Alt Phone (_____)_____________________________

E-mail address ____________________________________          Date of Birth _______________

Spouse’s Name _____________________________________     Spouse’s DoB ______________

 

Children:

Name: __________________________________  Sex:   M  F    Date of Birth: _______________

Name: __________________________________  Sex:   M  F    Date of Birth: _______________

Name: __________________________________  Sex:   M  F    Date of Birth: _______________

Name: __________________________________  Sex:   M  F    Date of Birth: _______________

Name: __________________________________  Sex:   M  F    Date of Birth: _______________

 

Other Family members:

Name: _________________________ Sex:   M  F    DOB: ________  Relationship: __________

Name: _________________________ Sex:   M  F    DOB: ________  Relationship: __________

Name: _________________________ Sex:   M  F    DOB: ________  Relationship: __________

Name: _________________________ Sex:   M  F    DOB: ________  Relationship: __________

Attached is a check for my first month’s membership fee and my one-time processing fee.  Direct Concepts will send me coupons for my monthly payments that will be due by the 20^th of each month for the next month’s payment.  I understand that Direct Concepts has the right to cancel my membership for non-payment.  I further agree that if any check is not honored for any reason, Plan Administrator will not be under any legal liability to provide benefits, even though my bank’s refusal results in forfeiture of my benefits and my membership in this Plan. I further agree that this authorization is to remain in effect until Plan Administrator receives written notice of my desire to cancel my Membership, or when Plan Administrator notifies me that my Membership has been cancelled.

Signature (required)                                                                                        Date

(Last revised 04-17-07)

 

Producer: __________________________________________________

Please mail completed form to:  Direct Concepts – 9720 Tumble Lake Ct. – Las Vegas, NV  89147

Please note: Unsigned forms will not be processed.