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AMERIPLAN USA - USCCCNII
Sign Up For AmeriPlan USA Dental, Vision, Prescription and Chiropractic Coverage Here!
Home | AmeriPlan USA DENTAL and Much More! | FREE Vision Care Program Included | FREE Prescription and Pharmacy Program INCLUDED | FREE Chiropractic Care INCLUDED | AMERIPLAN USA Availability By State | Vital Links From USCCCN International, Incorporated | AmeriPlan USA Brokers Wanted | Let's Recap AMERIPLAN USA In Plain English | Sign Up For AmeriPlan USA Dental, Vision, Prescription and Chiropractic Coverage Here! | ATTENTION: All Local and Regional Sales Managers Everywhere!!! | ATTENTION: AmeriPlan Brokers, Sales Managers and Telemarketers Everywhere!

Welcome To AMERIPLAN USA! ........Sales Brokers Wanted!

CLICK HERE To Sign Up As An AmeriPlan Broker!

Or....

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:

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2.
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4.
5.
6.
7.
8.
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Please Send My AmerPlan Membership Materials in:

___English
___Spanish

*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.

CREDIT CARD PAYMENTS:

___Visa
___Master Card
___Discover
___American Express

Credit Card Number:

Expiration Date:

Name on Credit Card:

Applicant Signature:______________________________________


*30-Day Written Cancellation Notice Required

*A ONE-TIME $20.00 Registration Fee is Required with Each Application.

First Month Membership Fee:.................$
(Monthly Fee - $11.95 Single / $19.95 Family)

First Quarter Membership Fee................$
(Quarterly Fee - $35.85 Single / $59.85 Family)

First Year Membership Fee:..................$
(Annual Fee - $143.40 Single / $239.40 Family)

ONE-TIME REGISTRATION FEE...................$20.00


TOTAL AMOUNT DUE (Enclosed).........$________________
*(Please Remember to Also Enclose a Voided Check)

Thank You For Subscribing to AmeriPlan USA!


---The USCCCN II/AmeriPlan Staff

CLICK HERE To E-mail The USCCCN II AmeriPlan Staff



WOULD YOU LIKE TO RECEIVE AMERIPLAN USA BROKER DETAILS?

The Benefits of Becoming an AmeriPlan USA Broker:

*Automatic Upgrade to AmeriPlan Family Plan!

*No Inventory!

*No Overhead!

*No Need to Have An Office or Employees!

*The Perfect Home Business!

*Only 7 to 10 Hours of Work Commitment Per Week Needed!

*You May Eventually Be Able to FIRE YOUR BOSS!

*RESIDUAL INCOME While You Sleep!

*RESIDUAL INCOME While You Dine Out!

*RESIDUAL INCOME While You Spend Time with Your Family!

*RESIDUAL INCOME While You Vacation!

*RESIDUAL INCOME While You Relax or Play!

*RESIDUAL INCOME While You Plan Bigger and Better!

*RESIDUAL INCOME Willable to Your Beneficiaries!

*RESIDUAL INCOME You Can Enjoy Now!

*RESIDUAL INCOME You Can Spend Now!

*RESIDUAL INCOME Guaranteed from Your Successful Efforts!

*RESIDUAL INCOME In YOUR Pocket or Bank Account Now!


NOW - IF YOU ARE INTERESTED (Or Think You Might Be Interested) IN BECOMING AN AMERIPLAN USA BROKER.....

Please Copy The Form Below, Print It, Complete it and Enclose it With Your Membership/Enrollment Application, Your Check and a Voided Check.

Already Have a Business? You Can Add AmeriPlan USA to What You may Currently Be Doing, Through Your Company!

Please Send Me AmeriPlan USA Broker Details.

Name:

Name of Your Business:

Address:

City:

State:

Zip:

E-mail:

Telephone:

Or CLICK HERE To Enroll as an AmeriPlan Member Online!

Or CLICK HERE To Sign Up As An AmeriPlan Broker Online

CLICK HERE To E-mail The USCCCNII AmeriPlan Staff