Your Contact Details

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Full Name: * Address * Phone: * Email:

Your Card Usage

Please answer the questions below.

1. Do you have current coverage? Yes No 2. If yes, through what company? 3. How many people in the household would benefit from prescription discounts? 4. As a household, how much do you typically spend out of pocket on prescription medications per month?

Your Account

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Routing Number: * Account Number: * Check Number: *

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Name:
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Phone:
Email:
Coverage:
Coverage Company:
In Household:
Spending Monthly:
Routing Number:
Account Number:
Check Number:

You will be charged $39.95 per month.

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Your Account

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