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Applicant Information
 
Middle Initial    
First Name Sex  
           
Street Apartment No    
City State Zip
           
Work Phone

Email Address
Home Phone Date of Birth
       
Agent    
       
       
Dependent Information
       
       
Spouse
Middle Initial
First Name Date of Birth
       
Child
Middle Initial
First Name Date of Birth
       
Child
Middle Initial
First Name Date of Birth
       
Child
Middle Initial
First Name Date of Birth
       
Child
Middle Initial
First Name Date of Birth
       
Child
Middle Initial
First Name Date of Birth
       
       
Plan Selection and Method of Payment
       
Plan  
       
Start Date    
       
Credit Card   Bank EFT  
Account Name
Account Number
Routing Number
Card Type Bank Name
    Type of Account
       
       
By signing below you certify that the information contained herein is true to the best of your knowledge and belief and that you are authorized to make the this transaction.
       
Electronic Signature    
       
       
Authorization
I am applying for dental coverage, and by my electronic signature below I understand this dental plan is a one (1) year non-refundable program. I authorize the dentist who has rendered services to me or members of my family to make available to Smile Card my dental records, photocopies or information regarding such services to the extent permitted by law. I understand that my electronic signature provides the same authorization as that of an actual signature on an application.
       
Electronic Signature    

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