If You'd Like To Enroll By Mail (In Case You Are Using a Checking Account Draft Deduction Option and Not
a Credit Card, Complete and Mail to USCCCN International, Incorporated, enclosing a voided check.
AMERIPLAN USA ENROLLMENT
APPLICATION Dental, Vision, Prescription and Chiropractic Plan
INSTRUCTIONS FOR SUBSCRIBING TO AMERIPLAN
USA
FOR THE PURPOSES OF INFORMATION SECURITY, Please Print this Form, Complete the Entire Form, Enclose Your
Check (and a Voided Check) or Your Credit Card Information, and Mail it By USPS Mail to the Following Address:
USCCCN INTERNATIONAL, INCORPORATED AmeriPlan USA (11339999) Division Post Office Box 663 South Plainfield,
New Jersey 07080-0663
As Info: Fed. ID# 22-3248936
PLEASE INSERT YOUR SUBSCRIBER INFORMATION
First Name:
Middle Initial:
Last Name:
Date of Birth:
Male/Female:
Social Security Number:
Preferred Contact Phone:
Preferred E-mail Address:
Preferred Mailing Address:
Apt/Suite:
City:
State:
Zip:
Employer Name:
HOUSEHOLD MEMBERS:
Please List First and Last Names and Dates of Birth:
*I Understand That My Membership Is On an Annual Basis and
All Membership Fees are Non-Refunadble After 30 Days.
I Want to Pay My Monthly or Quarterly Membership Fees
By:
___Bank Draft on the THIRD DAY of The Month ___Bank Draft on the EIGHTEENTH DAY of The Month
By Submitting Your Enclosed Check, Payable to AMERIPLAN USA, You are Authorizing The Ongoing Draft Until AmeriPlan
is Notified of Cancellation in Writing.
*You Must Enclose Your Check for Payment AND A VOIDED CHECK if paying
Monthly or Quarterly By bank Draft.
*Invoicing is Available For Annual Memberships Only with First Year Paid
In Advance.
