Form Page: NewMemberApplication

OUR FAMILY WISHES NEW MEMBER APPLICATION

Today's Date

How did you hear about us?

Referred by

Monthly Membership Plan Type (Select One)

Annual Savings One Month Off (Select One)

SILVER - $55 monthly

GOLD - $85 monthly

PLATINUM - $125 monthly

SILVER - $605 Annual

GOLD - $935 Annual

PLATINUM - $1,375 Annual

Member #1

First Name

Last Name

Date of Birth

Member #2

Relationship to Plan-keeper

City

State

Funeral Home Provider

First Name

Last Name

Relationship to Plan-keeper

Member #3

City

State

Funeral Home Provider

First Name

Last Name

Relationship to Plan-keeper

Member #4

City

State

Funeral Home Provider

First Name

Last Name

Relationship to Plan-keeper

Member #5

Funeral Home Provider

First Name

Last Name

Relationship to Plan-keeper

City

State

Funeral Home Provider

Plan Keeper (Payor) Information

First Name

Last Name

Cell Phone

Secondary Phone

Email_Payor

Billing Address

City

State

Zip Code

Please enter the code above in the box below.

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1. Are any of the enrolling members diagnosed as being terminally ill?

2. Are any of the enrolling members confined to hospice, hospital, or nursing home?

3. Are any of your enrolling members diagnosed with cancer or receiving any treatment including maintenance medications?

As allowed by the U.S. Electronic Signatures in Global and National Commerce Act (eSign law), we use electronic signatures on business sales agreements. Please read carefully:

By typing your name into the signature box you are agreeing to use an electronic signature, which means:

• You agree to use an electronic document and an electronic signature. You understand that electronic signatures are legally binding in the United States and other countries.

• You agree to read the document and fill it out accurately and completely.

• Your web browser must be configured to accept cookies.

• After you sign, the system will email you a document allowing you to access and download your signed, legal original document.

I Agree to the

Terms and Conditions