Student Information (Items in RED must be filled in)
Student Name:
Mailing Address:
City:
State:	Zip Code:
Phone:	###-###-####    FAX ###-###-####
Student E-mail:	Gender   Choose Male Female
Date of Birth:	MM/DD/YYYY                  Student ID#
Billing Information (Items in RED must be filled in)
Name:
Street Address:
City:
State:	Zip Code:
Phone:	###-###-####
FAX:	###-###-####
Your E-mail:
Credit Card Information
Credit Card:	(No spaces or dashes)      EXP DT: (MM/YY) We accept  VISA/Mastercard
Card ID #:

Choose the Appropriate Catastrophic plan option

Type Description / Price Student Plan Select the appropriate plan ------------------------------ Student UNDER 25 - Annual Rate - $ 185.00 Student -25 AND OVER - Annual Rate - $360

Other Questions, Comments, or Requests: