Administered by:
Golden Age Administrators
Div. of Golden Age Companies
6800 South Bay Rd., Cicero, NY 13039
(315) 698-9800  (800) 270-2226  Fax: 315-698-9807
 

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Disclaimer


Sign up online with check (Checkomatic)

To sign up by mail, click here to for a printable enrollment form

          For available membership plans and rates, please go our Membership Plans page.                    We do not share any information you provide us with anyone. For our complete privacy statement you may go to Our Privacy Policy & Privacy Statement section.

Please provide the following personal and banking information:

       * First/Last Name                             *Date of Birth             *Social Security Number
 
      *Street Address                       Apt#             *City                 *State            *Zip
             

*Home Phone        Bus. Phone           *E-mail                   Employer/Union          *Retired            

  YesNo
* Plan type selected (check one)  Myself only     Myself & Spouse   Myself & Family

Additional Household Members To Be Enrolled

           Spouse Name                    DOB            Additional Children's Name          DOB
   
         Children's Name                  DOB  
   
   

Bank Account Information 

Please complete the form below and void the check number you use for this transaction
  *Account Holder Name                 *Bank's Name                                *Account Type 

                   

        *Bank Account #                       *Bank Routing # (9 digits)       *Amount Paid  *Check #

             

*Please debit the above account for     this transaction only   all future membership fees
*Please bill me at the following frequencies:    **Quarterly  **Semi Annual    **Annual

*   These fields must be completed before submitting form.                                                           ** Quarterly or Semi Annual billing is available only by using checkomatic billing.                     ** Annual billing is available either by checkomatic or direct billing by mail.                               To be billed by mail the next due date please select debit account for this transaction only

By submitting this form, I agree that I have read and fully understand the Disclaimer and Limitations & Exclusions for membership in the Golden Age Dental Network as stated on this website.   I also understand that my membership will be effective immediately upon your receipt and acceptance of this form.  I am applying for a membership in the the Golden Age Dental Network and agree to remain a member for a minimum of one year.                    

  I Agree

      

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