Customer Enrollment Form

Member Information
Customer Name:
Date of birth:
Social Security Number:
Gender:	Male Female
Street Address
City:
State:
Zip:
Telephone:
email address:
Present / Previous Employer:
Do you carry Dental / Health Insurance?	Yes If yes, Company Name:

Membership Inclusion

I would like my membership in the Progresive Dental Network to include:

Membership Information

I would like my membership in the Progresive Dental Network to include:
Myself only
Myself & Spouse Spouse Name: Spouse DOB:
Myself & Family

1. Name: DOB:
2. Name: DOB:
3. Name: DOB:
4. Name: DOB:
5. Name: DOB:

Billing Method

Direct Billing. (mail check for annual membership)

Checkomatic (your payment will be deducted directly from your bank account. Please complete the authorization form below to establish this billing method.

Name on Check: Bank Name:
Account #: Routing #: Check #:
Amount: Paid $

By submitting this enrollment form and selecting the “Checkomatic” billing method, I am authorizing Golden Age Administrators to deduct the appropriate PDN membership fees from my bank account as listed bellow. Please debit my account for: All future membership fees This transaction only

Plan Participation

By submitting and signing this form, I state that I have read and fully understand the terms and conditions of this membership. I have read the “disclaimer” and the “Important Network Information” described in the Progressive Dental Network brochure and/or website. I also understand that my membership will be effective immediately upon receipt and acceptance of this form. I understand that my membership will be terminated if I fail to pay the agreed membership fee within 30 days of receipt of an invoice. I am applying for membership in the Progressive Dental Network administered by Golden Age Administrators. I agree to keep my membership for a minimum of one (1) year.

Phone: 315-698-9800 / 800-270-2226 FAX: 315-698-9807

For more information please email info@ progressivedentalnetwork.com