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P.O. BOX 683006
HOUSTON, TEXAS 77268-3006
281-580-4111 • 800-880-4343
FAX 281-580-0933 |
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ADVANTAGE PLAN
ENROLLMENT FORM
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1. There is a one time enrollment fee of $25 per family.
2. Dependent children are included at NO MONTHLY FEE.
3. Please check one box below.
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1 ADULT FAMILY |
2 ADULT FAMILY |
PAY |
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Annual
Billing |
$70.00 |
$95.00 |
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5
Month Billing |
35.00 |
60.00 |
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Monthly
Bank Draft |
7.00 |
12.00 |
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| One-time
enrollment processing fee |
+
$25.00 |
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Remit
this amount: $
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(FOR BANK DRAFT ONLY) Sign this authorization and attach void check plus check for first month's fee an
enrollment fee.
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BANK DRAFT AUTHORIZATION: I hereby request and authorize you to pay checks drawn on my account by DDS provided there
are sufficient funds in said account to pay the same upon presentation.
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X____________________________________
Signature
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4. Indicate your method of payment here.
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Check / Money Order: |
Please attach 1 check for $25 enrollment fee and Monthly, 5 Month or Annual payment.
Make check payable to Dorsey Discount Services. |
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Card Number |
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Expiration |
___/___ |
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Signature |
X_____________________________________ |
Amount $ |
___.___ |
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AGREEMENT
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Please enroll me in Dorsey Discount Services. I understand that I will receive an I.D. card which entitles me to receive substantial discounts on
goods and services from the participating businesses.
| Date
____________________________________ |
Second Adult ____________________________ |
| Name ___________________________________ |
Employer ________________________________ |
| Address _________________________________ |
Home Phone _____________________________ |
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Work Phone _____________________________ |
| Employer ________________________________ |
Name and Ages of Children
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| _________________________________________ |
_________________________________________ |
| Do you presently have a dental insurance policy?
__________________________________ |
(Refer to "Coordination of Benefits" on back of Fee Schedule.) |
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X_____________________________________
Signature |
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MAIL TO:
Dorsey Discount Services
P.O. Box 683006
Houston, Texas 77268-3006 |
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FOR OFFICE USE ONLY
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Agent Number D447
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Client Number ____________
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Effective Date ____________
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DDS 101
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