1. SEND INITIAL ENROLLMENT FEE: $30
2. CHOOSE A PAYMENT PLAN:
Monthly Annual
$29.95 $359.40

THIS FORM IS FOR MAIL IN ONLY! There is link at the bottom for printing this page and another link to provide the correct address for mailing. You can go to our secured submission form via Internet here.

3. CHOOSE A PAYMENT METHOD:
Credit Card: VISA, MASTERCARD, DISCOVER or AMEX - complete authorization below
Electronic Bank Draft ( EFT/ACH ) - complete authorization below ( most convenient choice )
I hereby authorize Liberty Legal, Inc., D.B.A. Liberty Benefits to charge/draft my credit card, as listed below or my checking/savings account from the financial institution listed on my voided check. I agree that if any charge is dishonored, whether intentionally or inadvertently, Liberty Benefits Prescription Program shall be under no liability whatsoever. This authority is to remain in effect until Liberty Benefits Prescription Program receives written notification from me revoking the authorization. Your account will become effective on the 1st of the month following the date of enrollment. Signature is required for credit card or EFT method of payment.
  Signature of Account Holder (or POA)
  Credit Card Number:
  Expiration Date: (Month) (Year)
 
Type of Card: Visa MasterCard Discover Amex
  Bank Routing Number
  Bank Account Number

OFFICE USE ONLY/ DATE RECEIVED:
CHECK NUMBER:
IBO SELLING AGENT: ---Betty L. Held
NUMBER:--- 4623501