Justin Elder - GLOBAL MEDEVAC - MEMBER ENROLLMENT APPLICATION

Global Medevac

Member Enrollment Application
NAME: (First M. Last)
SPOUSE:(First M. Last)
Member Birthdate:

MonthDayYear
Date
Spouse Birthdate:

MonthDayYear
Date
Member Age:
Spouse Age:
Home/Benefits Address:
City:
State:
Zip:
Email:
example@example.com
Phone:
Dependents:
Name - Date of Birth - Age
Signature: I attest that the above information is accurate and correct
Date

MonthDayYear
Date
Choose Your Plan

Please select just one
Monthly Premier Plan
Annual Premier Plan
5-Year Premier Plan
Lifetime Premier Plus Plan
All plans include a $60 application fee

(Fees waived for the Lifetime Premier Plan)
NOTE: THIS APPLICATION IS NOT A CONTRACT.

You will be called by our billing department prior to any processing of your information.
PAYMENT INFORMATION
CREDIT CARD INFORMATION
City:
State:
Zip:
Card Number:
Exp Date:

MonthDayYear
Date
SVC Code:
Authorized Automatic Renewal?
By accepting, you agree to continue with yearly renewals until membership termination.
Credit Card Signature
EFT/ACH/BankAccount
Bank Name:
Acct #:
Routing #:
Amount to be debited:
Bank Account Signature
Seminar Location (City, State)
Agent ID
Please verify that you are human
Should be Empty:

Global Medevac