Member Information
First Name
MI
Last Name
Date of Birth
Address
City
State
Zip
Company
Phone
Fax
E-mail
Type of Membership

Employee Only

 Employee + One

Employee + Family
Dependents Covered
Last Name First Name

    Middle Name
I hereby make application for membership in Dental Resource Group. I agree to hold Dental Resource Group harmless from any liability for negligence on the part of an Affiliated Dentist. I further release Dental Resource Group from and waive any claims for negligent referral, negligent certification or similar claim. I hereby authorize my employer to make payroll deductions, if required, for the coverage selected.

 
Date