2009-2010 STU-DENT REGISTRATION FORM
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Name (First)		(Last)
Primary Member	__ NEW ($225)			__ RENEWAL ($185)
Appointment (Check One)	__ DAY			__ EVENING
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Local Address				Apartment #
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City/State/Zip
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Telephone		Student ID # or Social Security #.
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Date of Birth				Sex __ F __ M
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Which School
Year	__ Freshman __ Sophomore __ Junior __ Senior __ Grad Student
Additional Members
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Name (First)		(Last)
Partner	__ NEW ($225)			__ RENEWAL ($185)
Appointment (Check One)	__ DAY			__ EVENING
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Soc. Sec. No.	Date of Birth			Sex __ F __ M
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Address (if different than primary member's)
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City/State/Zip
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Name (First)		(Last)
Dependent	__ NEW ($80)			__ RENEWAL ($80)
Appointment (Check One)	__ DAY			__ EVENING
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Soc. Sec. No.	Date of Birth			Sex __ F __ M
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Address (if different than primary member's)
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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
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Credit Card Number		Expiration Date
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Name on Credit Card
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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
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Chart No.	Clinic Assignment