Prescription Benefit Card Enrollment Form

 

To Enroll, Please Complete The Form Below.  Each new member will receive a card.

Primary:

First Name:

MI:

Last Name:

Your Sex: Male Female (Select One)

Birth Date:  / /  (xx/xx/xxxx)

Ship To Address:    

City:

State: 

Zip Code:

Phone:

Email:  

 

Enrollment Information For Additional Individuals To Be Covered.

 

Spouse:

First Name:

MI:  

Last Name:

Sex:  Male  Female (Select One) 

Birth Date:  / /  (xx/xx/xxxx)

 

Dependent 1:

First Name:

MI:  

Last Name:

Sex:  Male  Female (Select One)    

Birth Date:  / /  (xx/xx/xxxx)

 

Dependent 2:

First Name:  

MI:  

Last Name:

Sex:  Male  Female (Select One)

Birth Date:  / /  (xx/xx/xxxx)

 

Dependent 3:

First Name:  

MI:  

Last Name:  

Sex:  Male  Female (Select One)

Birth Date:  / /  (xx/xx/xxxx)

 

Dependent 4:

First Name:

MI:  

Last Name:

Sex:  Male  Female (Select One)

Birth Date:  / /  (xx/xx/xxxx)

 

Dependent 5:

First Name:

MI:

Last Name:

Sex:  Male  Female (Select One)

Birth Date:  / /  (xx/xx/xxxx)

 

Dependent 6:

First Name:

MI:

Last Name:

Sex:  Male  Female (Select One)

Birth Date:  / /  (xx/xx/xxxx)

 

Dependent 7:

First Name:

MI:

Last Name:

Sex:  Male  Female (Select One)

Birth Date:  / /  (xx/xx/xxxx)

 

Dependent 8:

First Name:

MI:

Last Name:

Sex:  Male  Female (Select One) 

Birth Date:  / /  (xx/xx/xxxx)

 

Dependent 9:

First Name:

MI:

Last Name:

Sex:  Male  Female (Select One)

Birth Date:  / /  (xx/xx/xxxx)

 

Dependent 10:

First Name:

MI:

Last Name:

Sex:  Male  Female (Select One)

Birth Date:  / /  (xx/xx/xxxx)


Select One


If necessary, please add additional dependents on another page using this same format.> Enclose your check or money order.  Prescription benefit card, instructions and information will be mailed to you upon receipt of payment. Please allow 5-7 days for delivery.  All sales are final.  Pricing is based on annual membership.  Renewal notifications will be mailed annually. Thank you for purchasing our card and enjoy your savings.  Marketed by Garth Marketing Group. Services provided and managed by SPC Global Technologies, LTD.  


Send mail to travisgarth@myrxcard.com with questions or comments about this web site.
Copyright © 2001-2004 Garth Marketing Group
Last modified: February 19, 2004
Marketed by Garth Marketing Group.
Services provided and managed by SPC Global Technologies, Ltd.
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