AppleCare Advantage Enrollment Form

Name*

FirstLast

Prefer To Be Called

Sex*

Address*

Street AddressCityStateZip Code

Home Phone

Work Phone

Cell Phone

Best To Call

Best Time to Phone

Email*

Email AppleCare Newsletter?

Select Your Status*

Spouse or Parent's Name

Birth Date*

MM

DD

YYYY

Social Security Number*

Enter as 999-99-9999 with dashes

Employer's Name

If Student, School Name

School City/State

Current/Former AppleCare Patient?*

Whom may we thank for referring you?

Payment Terms

Select Your Membership Billing Plan:*

Payment Terms: There is a one-time enrollment fee of $9.95 per member, capped at $39.80 for families with four or more members. All monthly billing is automatically made to your choice of credit card or bank account on the 1st of the month. Before your first full month there is a prorated charge for individual days. Read the membership agreement

Person 2

Name*

FirstLast

Sex*

Birth Date*

MM

DD

YYYY

Social Security Number*

Enter as 999-99-9999 with dashes

Relationship To You*

Person 3

Name*

FirstLast

Sex*

Birth Date*

MM

DD

YYYY

Social Security Number*

Enter as 999-99-9999 with dashes

Relationship To You*

Person 4

Name*

FirstLast

Sex*

Birth Date*

MM

DD

YYYY

Social Security Number*

Enter as 999-99-9999 with dashes

Relationship To You*

Person 5

Name*

FirstLast

Sex*

Birth Date*

MM

DD

YYYY

Social Security Number*

Enter as 999-99-9999 with dashes

Relationship To You*

Person 6

Name*

FirstLast

Sex*

Birth Date*

MM

DD

YYYY

Social Security Number*

Enter as 999-99-9999 with dashes

Relationship To You*

Payment Choice

I agree to pay my application and membership fees as specified in the above "Payment Terms" using my...*

Credit/debit card
Bank checking account

Fill out the appropriate form below with the info about your card or bank account.

Pay by Credit Card or Debit Card

Type of Card*

Card Number*

Enter numbers only (no spaces or punctuation)

Month*

Year*

Card Code Verification*

Please enter a value between 001 and 9999.

Pay by Bank Checking Account

We will deduct payment directly from your checking account.

Bank Name*

Routing Number*

Please enter a value between 000000001 and 999999999.

Enter 9 numbers with no spaces or dashes.

Account Number*

Please enter a value between 0000000001 and 99999999999999999.

Enter all numbers with no spaces or dashes

Bank Account Type*

Company Name Exactly As On Checks*

Enter up to 22 characters including spaces. No punctuation allowed.

Billing Name, Phone and Address

Enter the info associated with your credit card or bank account

Name Exactly As on Your Card or Bank Account*

Enter up to 22 characters including spaces. No punctuation allowed.

Billing Phone*

Phone on your card or account

Billing Address*

Street AddressCityStateZip Code

Address on your card or account

Verification

*

I agree to the AppleCare Advantage Program Membership Agreement which I have read.

Read the agreement

Type the two words (prevents computer spam)

Doctor’s Clinics

Inside AppleCare

Advantage Program

Payment Terms

Person 2

Person 3

Person 4

Person 5

Person 6

Payment Choice

Pay by Credit Card or Debit Card

Pay by Bank Checking Account

Billing Name, Phone and Address

Verification