Please provide the following contact information:

First Name
Last Name
Middle Initial
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Home Phone

Date of Birth	-- mm/dd/yy
Sex	Male Female

Social Security Number    

Membership Applying For:     Associate Membership  Executive Membership   Platinum Membership

I hereby enroll in the CARE Association.

Date Signed:-- mm/dd/yy    

Insured Signature: 

 Please type your name the second time below for the confirmation of your signature.

Insured Signature:

 Credit Card Payment for Monthly Dues ($1 for Associate Membership or $4 for Executive Membership or $7 for Platinum Membership)

*There is a 4% service fee for this option

VISA  MasterCard

Account Number            -- (####-####-####-####)

Expiration Date      -- mm/yy

Name as it appears on the Card    

Electronic Signature:

Insured Signature: 

 Please type your name the second time below for the confirmation of your signature.

Insured Signature:

By completing & submitting  this internet form you are enrolling in CARE and your credit card will be charged for the appropriate monthly dues.

Cancellations are requested in writing, mailed to Greater Insurance Service Corp. at 414 Atlas Ave, Madison, WI  5714-3165 OR faxed to( 608) 221-0868.   Cancellation request must include:  your name (please print), the last four digits of your SSN, requested cancellation date,  and signature.  Cancellation date will be the later of your requested date or the first of the month after written notice is received.