Direction: Please fill out this form by using your keyboard. Click "Print Enrollment Form" to print this form. First Name:  Last Name:  Address:  City:  State:  Zip:  Phone:  Email:  Date of Birth: //  mm/dd/yyyy Social Security # (Optional): _____/____/___________ Check Membership Fee: White - CHOOSE ANY 2 $79.99 Silver - CHOOSE ANY 3 $99.99 Gold - CHOOSE ANY 4 $119.99 Platinum - ALL 6 BENEFITS $179.99 Check Benefits You Prefer:  Vision Care  Prescription Drug Card  Dental Care  Chiropractic Care  Alternative Medicine  Nurse Hotline Mail with check payable to       National Health Benefits       2920 Hillside Dr.       Highland Village, TX 75077 ADDITIONAL MEMBERSHIP CARDS. Cost $3.50 each. List cardholders names:   Card1: First  MI  Last    Card2: First  MI  Last  Total:  Click to print Enrollment Form Copyright © 1991-2005 by National Health Benefits. All rights reserved. (888) 224-2258 -- info@NationalHealthBenefits.com This is not insurance but a discount health care program. Program void where prohibited by law. California, Florida and South Dakota residents are excluded from this offer.