Wellness Plan Application

To qualify for a plan with monthly payments, the Wellness Plan program requires a Valid Drivers License or State ID, a Bank Acct Number (checking or savings) and Major Credit Card, or two Major Credit Cards.

Wellness Plan Application
File Size:	156 kb
File Type:	docx

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Owner Information:

* Indicates required field

Name *

First

Last

Phone Number *

Cell Phone Number (Optional) *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Rent/Own *

How long at current address? *

Email Address *

Current Drivers License Number *

SSN *

Drivers License Date *

Employer Information:

Employer Name *

Work Phone Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

How long? *

Payment Information:

Please enter two of the following.

Bank Account

Routing Number *

Bank Acct Number *

Debit/Credit Card

Name on Debit/Credit Card *

Debit/Credit Card Number *

Exp. Date *

CVC *

Additional Card

Name on 2nd Credit/Debit Card *

2nd Debit/Credit Card *

Exp. Date *

CVC *

Confirmation *

The above information is accurate and true.

Signature *

Date *

Submit