| 2009-2010 STU-DENT REGISTRATION FORM |
| |
| _______________________________________________________________________ |
| Name (First) |
(Last) |
| Primary
Member |
__ NEW
($225) |
|
__
RENEWAL ($185) |
| Appointment
(Check One) |
__ DAY |
|
__
EVENING |
| |
|
|
| _______________________________________________________________________ |
| Local
Address |
|
Apartment
# |
| _______________________________________________________________________ |
| City/State/Zip |
|
|
| _______________________________________________________________________ |
| Telephone |
|
Student
ID # or Social Security #. |
| _______________________________________________________________________ |
| Date of
Birth |
|
Sex __
F __ M |
| _______________________________________________________________________ |
| Which
School |
|
| Year |
__
Freshman __ Sophomore __ Junior __ Senior __ Grad Student |
| |
| Additional
Members |
| |
| _______________________________________________________________________ |
| Name (First) |
(Last) |
|
| Partner |
__ NEW
($225) |
|
__
RENEWAL ($185) |
| Appointment
(Check One) |
__ DAY |
|
__
EVENING |
| |
| _______________________________________________________________________ |
| Soc. Sec.
No. |
Date of
Birth |
|
|
Sex __
F __ M |
| _______________________________________________________________________ |
| Address
(if different than primary member's) |
|
| _______________________________________________________________________ |
| City/State/Zip |
|
|
| |
|
|
| _______________________________________________________________________ |
| Name (First) |
(Last) |
|
| Dependent |
__ NEW
($80) |
|
__
RENEWAL ($80) |
| Appointment
(Check One) |
__ DAY |
|
__
EVENING |
| |
|
|
| _______________________________________________________________________ |
| Soc. Sec.
No. |
Date of
Birth |
|
Sex __
F __ M |
| _______________________________________________________________________ |
| Address
(if different than primary member's) |
|
| _______________________________________________________________________ |
| City/State/Zip |
|
|
| Check made payable
to: |
Stu-Dent Plan,
NYU College of Dentistry |
| Mail
to: |
New York University
College of Dentistry
THE NYU STU-DENT PLAN
NYU Dental Faculty Practice
726 Broadway Suite 350
New York, NY 10211-2774 |
|
| |
| To
enroll or renew by Credit Card: |
| _ Visa
_ MasterCard _ Discover _ American Express |
|
|
| ______________________________________ |
_________________ |
| Credit
Card Number |
Expiration
Date |
| ______________________________________ |
|
|
| Name on
Credit Card |
|
|
| ______________________________________ |
|
|
| Authorizing
Signature |
|
|
| |
| # New Members |
___________ |
x $225.00
= |
$______________ |
| # Renewing Members |
___________ |
x
$185.00 = |
$______________ |
| # Dependents (Under
16) : |
___________ |
x $80.00
= |
$______________ |
| |
Total Amount of Charge: |
|
$______________ |
| |
|
|
|
|
| For
Office Use Only |
| |
| _______________________________________________________________________ |
| Chart No. |
Clinic
Assignment |
|