APPLICATION - AUTHORIZATION:

I wish to become a member of APPLE DENTAL and understand my membership is on an annual basis and that i can terminate it on any anniversary date of my initial enrollment. It is my understanding i have to option of paying for the membership on an annual or monthly basis. The latter will include two monthly payments plus $30.00 enrollment fee. (FIRST YEAR ONLY) For monthly membership payment, I authorize the company to initiate debit entries to my (our) checking account or credit card. I understand it is the responsibility of APPLE DENTAL and myself to keep my membership in force. To guarantee uninterrupted service I approve of the Company's automatic monthly renewal of my membership upon expiration. this authority shall remain in effect until revoked by me in writing. i reserve the right to pay for membership on an annual basis if i desire. By accepting the plan, I am accepting the terms of this application and permission to be called by the company's computers.