MedAdvantage Card

_________________________________________________________________
If you prefer, you may copy and paste the form below into a word processor, print it, complete the form and mail to:


MedAdvantage
P.O. Box 2230
Birmingham, MI. 48012

Safety and confidentiality are assured.



Name:________________________________________

Social Security Number: __ __ __ - __ __ - __ __ __ __
Address:___________________________________________________
City:_______________________ State:_________ Zip:_________
Home Ph.(      )________________
Bus. Ph.(      )________________
Birthdate: ______/_____/_____     M__ F__
Spouse:__________________________ Birthdate:______/____/____
Dep._____________________________ Birthdate:______/_____/____
Dep._____________________________ Birthdate:______/_____/____

Signiature:____________________________________________

   I authorize MedAdvantage to register and charge this credit/debit card for any purhcases I make. I understand that revocation of my credit/debit card may cancel MedAdvantage membership privileges.

___ VISA ___ MASTERCARD ___ DISCOVER ___ BANK DEBIT CARD

Exp. Date: ____________________
Name of Cardholder:_______________________________________
Card #_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _



Return to

LUPUS LINKS

~~ OR ~~


You May Choose A Room Below:

(Before clicking on a link, make sure the WATERMARK is out of the way)

butterfly bar



1