Step 1 - ADG Enrollment Form

Last Name*
First Name*
Initial
Date of Birth*	Select: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Select: 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Select: 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920
Gender*	Male Female
Email Address*
Phone #*
Alt. Phone #
Residence Address*
City*
State*	Select One: CO MD PA
Zip Code*
* Required

Step 2 - ADG Enrollment Form

Please choose a plan type:

Single

Family

Step 3 - ADG Enrollment Form

Please choose a rate that applies to you: (if none apply please choose none)

Senior

Latino Chamber of Commerce

none

Step 4 - ADG Enrollment Form

Please choose a payment frequency:

Monthly

Annually

Step 2a - ADG Enrollment Form

Please give us the full names (as you want them to appear) of all household members to be included in this plan:

Step 5 - ADG Enrollment Form

Please choose your method of payment:

Automatic Credit Card / Debit Card

Automatic Bank Account Withdrawl

Step 5 - ADG Enrollment Form

Please choose your method of payment:

Automatic Credit Card / Debit Card

Annual Direct Bill

Summary - ADG Enrollment Application

Name:	Smith
Date of Birth:	Smith
Phone #:	Smith
Alt. Phone #:	Smith
Email Address:	Smith
Residence Address:	Smith

Please check the information above for accuracy. Please complete the form below. For your security we would like you to print it out and either mail it or fax it to us.

Mailing Address: PO Box 25517 Colorado Springs, CO 80917 Fax Number: (719)633-3025 Phone Number: (800)633-3010 or (719)633-3000

For immediate membership please call American Dental Group.

Please enter your credit card information. Your membership will start when we receive your payment.

Mastercard

Visa

Discover

American Express

Credit Card Number

Exp. Date

Select One: January February March April May June July August September October November December Select One: 2009 2010 2011 2012 2013

Security Code (on the back of your card):

Your credit card will be charged the amount below for the first year.
The member fee is the amount that will be charged each year following.

Enrollment Fee (one time):	$20.00
Member Fee:
Total (today):

I hearby make application to enroll in the American Dental Group (ADG) plan
for a MINIMUM OF ONE YEAR (subject to the guarentee period, if any). Member
holds ADG, its agents and assigns blameless for any negligence on the part
of any participating provider. This agreement can be terminated by ADG without
cause upon written notification to the above address. By signing below, I
authorize payment as indicated above.
X______________________________________________________
            Signature                                                 Date

Summary - ADG Enrollment Application

Name:	Smith
Date of Birth:	Smith
Phone #:	Smith
Alt. Phone #:	Smith
Email Address:	Smith
Residence Address:	Smith

Please check the information above for accuracy. Please complete the form below. For your security we would like you to print it out and either mail it or fax it to us.

Mailing Address: PO Box 25517 Colorado Springs, CO 80917 Fax Number: (719)633-3025 Phone Number: (800)633-3010 or (719)633-3000

For immediate membership call American Dental Group.

Please enter your credit card information. Your membership will start when we receive your payment.

Mastercard

Visa

Discover

American Express

Credit Card Number

Exp. Date

Select One: January February March April May June July August September October November December Select One: 2009 2010 2011 2012 2013

Security Code (on the back of your card):

Your credit card will be charged the first and last months' membership fees,
and the one time only enrollment fee. The member fee is the amount that will
be charged each month following.

Enrollment Fee (one time):	$20.00
First Month (this is also your Member Fee):
Last Month:
Total (today):

I hearby make application to enroll in the American Dental Group (ADG) plan
for a MINIMUM OF ONE YEAR (subject to the guarentee period, if any). Member
holds ADG, its agents and assigns blameless for any negligence on the part
of any participating provider. This agreement can be terminated by ADG without
cause upon written notification to the above address. By signing below, I
authorize payment as indicated above.
X______________________________________________________
            Signature                                                 Date

Summary - ADG Enrollment Application

Name:	Smith
Date of Birth:	Smith
Phone #:	Smith
Alt. Phone #:	Smith
Email Address:	Smith
Residence Address:	Smith

Please check the information above for accuracy. Please complete the form below. For your security we would like you to print it out and either mail it or fax it to us.

Mailing Address: PO Box 25517 Colorado Springs, CO 80917 Fax Number: (719)633-3025 Phone Number: (800)633-3010 or (719)633-3000

For immediate membership please call American Dental Group.

Please mail a check for the amount below. Your membership will start when we receive your payment.

Please enclose the enrollment fee plus the first and last months' membership fees.
The membership fees will be drafted from your account in the first week of each
month beginning next month. By submitting your enclosed check you are authorizing
us to charge your account by draft or electronic funds transfer amounts due as if
personally executed by you until you otherwise notify us in writing.

Enrollment Fee (one time):	$20.00
First Month (this is also your Member Fee):
Last Month:
Total (today):

I hearby make application to enroll in the American Dental Group (ADG) plan
for a MINIMUM OF ONE YEAR (subject to the guarentee period, if any). Member
holds ADG, its agents and assigns blameless for any negligence on the part
of any participating provider. This agreement can be terminated by ADG without
cause upon written notification to the above address. By signing below, I
authorize payment as indicated above.
X______________________________________________________
            Signature                                                 Date

Summary - ADG Enrollment Application

Name:	Smith
Date of Birth:	Smith
Phone #:	Smith
Alt. Phone #:	Smith
Email Address:	Smith
Residence Address:	Smith

Please check the information above for accuracy. Please follow the instructions below, print this out, and either mail it or fax it to us.

Mailing Address: PO Box 25517 Colorado Springs, CO 80917 Fax Number: (719)633-3025 Phone Number: (800)633-3010 or (719)633-3000

For immediate membership please call American Dental Group

Please send a check for the amount below. Your membership will start when we receive your payment. The first year's payment includes the $20.00 enrollment fee. Every year following will be billed to you at the member fee rate.

Enrollment Fee (one time):	$20.00
Member Fee:
Total (today):

I hearby make application to enroll in the American Dental Group (ADG) plan
for a MINIMUM OF ONE YEAR (subject to the guarentee period, if any). Member
holds ADG, its agents and assigns blameless for any negligence on the part
of any participating provider. This agreement can be terminated by ADG without
cause upon written notification to the above address. By signing below, I
authorize payment as indicated above.
X______________________________________________________
            Signature                                                 Date