Bushkill Emergency Corps
www.bushkillemergencycorps.com
2010-2011 Subscription Drive
ENROLLMENT FORM
Please Check one Make checks payable to Bushkill Emergency Corps
( ) $70.00 Household Bushkill Emergency Corps
( ) $50.00 Individuals or C/O PNC Bank
Seniors (60+) PO Box 4515
Philadelphia, Pa 19131-6515
List all immediate family members residing with you:
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Authorization: I authorize that payment of authorized Medicare Benefits or other insurance benefits be made on my behalf for any services furnished by this health service provider or supplier. I authorize any holder of medical information or documation about me to release to the Health Care Financing Administration and its carrier and/ or agents, as well as this health service provider, any information or documentation needed to determine these benefits or benefits payable for any service to me by this Health Service Provider now or in the future. |
Full Name Age 1. ______________________________ ______
2. ______________________________ ______
3. ______________________________ ______
4. ______________________________ ______
5. ______________________________ ______
6. ______________________________ ______ |
Signature X_____________________________ To validate subscription, form must be completed,
Print Name _____________________________ signed, and returned with payment of full amount.
Date __________________________________ Valid ONLY for persons listed.
Charge my: ( ) Visa ( ) Mastercard ( ) Discover ( ) American Express
Credit card# ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Expiration Date: ___ ___ / ___ ___ 3 or 4 digit code on card back: ___ ___ ___ ___
