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Personal Information
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Applicants Name : |
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*Last |
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Date of Birth :
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Sex :
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Male
Female
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*Address :
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Apt. :
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*City :
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*State :
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*Zip :
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*Telephone :
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Fax :
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*Email Address :
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Spouse’s Name
(Last, First, Middle) :
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Date of Birth :
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Dependent
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Date of Birth
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Relationship
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Name (Last, First, Middle) |
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Name (Last, First, Middle) |
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Name (Last, First, Middle) |
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Name (Last, First, Middle) |
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Pricing |
Individual OptimumRX Plan: $19.99/month |
Family OptimumRX Plan: $29.99/month |
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30-Day Money Back Guarantee
Get 2 additional months with annual subscription paid by credit card (first year
only) |
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*Plan Options
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Payment: $ |
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We accept the following debit and credit cards:
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We also accept personal check.
A statement fee of $5 per month will be added to subscription paid by check.
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*Terms
and Condition
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OPTIMUMRX CARD, INC. |
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www.optimumrxcard.com |
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Park 80 Center Park 80 West, Plaza II, Suite 200 •
Saddle Brook, New Jersey 07663 • Telephone: 201.568.1948 • Fax: 201.503.8099
• Toll Free: 866.333.3000 |
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