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"JOIN A DRUG PLAN THAT ALLOWS YOU TO USE YOUR LOCAL PHARMACY FOR ONLY $3.00 PER MONTH AND IT COVERS YOUR ENTIRE FAMILY"

PRESCRIPTION SAVINGS PLANS ENROLLMENT FORM

Member Information (Cardholder)

Social Security Number: ___-__-____         Date of Birth:  ___-___-___         Sex:  ______

   Last Name: ______________       First Name:  _____________       Phone: (___) _________

        Street:  ___________________       City:  ____________       State: ______       Zip: __________

Spouse and Dependent(s) Information

INSTRUCTIONS

Fee is $3.33 Per Month and covers member, spouse and dependents living in the same household.

To enroll, simply print and complete this form, enclose it with your check for $39.95 made payable to Prescription Savings Plans and mail to:

Enrollment Office
Prescription Savings Plan, Inc.
PO Box 220
Davison, MI 48423