AmeriPlan ® Discount Programs Membership Application
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 Member Information
 First Name
MI
  Last Name
                                 
 
                                   
 Date of Birth of Applicant Male/Female  Residence or Work Telephone          Alternate Telephone
   
   
   
 
 
     
     
       
     
     
       
 Mailing Address                    Apt.#
                                                                 
       
 City   State                Zip  
                                               
   
         
 Household Members
First Name Last Name         Date of Birth LIST
ADDITIONAL
HOUSEHOLD
MEMBERS ON A
SEPARATE SHEET
OF PAPER.
                       
                       
   
 
   
 
   
                       
                       
   
 
   
 
   
                       
                       
   
 
   
 
   
                       
                       
   
 
   
 
   
                       
                       
   
 
   
 
   
 E-MAIL ADDRESS Membership Fees
AmeriPlan® Corporation   
5700 Democracy Drive
Plano, TX 75024
A Discount Medical Plan Organization
AmeriPlan Health® is NOT insurance.
 I WANT TO PAY MY MONTHLY OR QUARTERLY MEMBERSHIP FEE BY:

 BANK DRAFT:  Please Draft on the
 
3rd  or
 
18th of the month.
By Submitting your enclosed check, you are authorizing the ongoing draft     
until AmeriPlan® is notified of cancellation in writing.
X                                                           
SIGNATURE FOR BANK DRAFT
 
CREDIT CARD:
    
 Visa   
    
 Master Card
    
 Discover   
    
 American Express
Card #      Expiration Date
                               
        
   
 
   
   
X                                                           
SIGNATURE FOR CREDIT CARD

Complete and fax (469-229-4589)
or mail application to:
AmeriPlan®
5700 Democracy Drive, Plano, Texas 95024
Attn: Application Processing
      Choice #1       Choice #2
 
Dental Plus
 
Monthly Fee - $19.95
 
Quarterly Fee - $59.85
 
Annual Fee - $239.40
 
Basic Health
 
Monthly Fee - $29.95
 
Quarterly Fee - $89.85
 
Annual Fee - $350.40
     Choice #3      Choice #4
 
Total Health
 
Monthly Fee - $39.95
 
Quarterly Fee - $119.85
 
Annual Fee - $479.40
 
Health Plus
 
Monthly Fee - $59.95
 
Quarterly Fee - $179.85
 
Annual Fee - $719.40
 
 First Month Membership Fee
  Monthly Fee - $19.95 /29.95/39.95/59.95
$
 First Quarter Membership Fee
  Quarterly Fee - $59.85/$89.85/$119.85/$179.85
$
  Annual Membership Fee
  Annual Fee - $239.40/$350.40/$479.40/$719.40
$
 One-time Registration Fee
         
$

Dental Plus Registration Fee               $20.00
Basic Health Registration Fee             $30.00
Total Health Registration Fee              $30.00
Health Plus Registration Fee               $30.00

NON REFUNDABLE
 TOTAL AMOUNT DUE  
$
MONTHLY OR QUARTERLY PAYMENTS MUST BE MADE BY ELECTRONIC BANK DRAFT OR BY CREDIT CARD.
INVOICING IS AVAILABLE FOR ANNUAL MEMBERSHIPS ONLY WITH FIRST YEAR PAID IN ADVANCE.
Enclose your check for payment and a voided check if paying monthly or quarterly by bank draft.  30-day written cancellation notice required.