*Name                                                                                                    *Birth Date
    Member:                    
                                First                        MI                    Last                                      mm/dd/yyyy

                     *Name                                                                                                  *Birth Date
     Spouse:                    
                                 First                       MI                    Last                                      mm/dd/yyyy

  Dependant:                  
  Dependant:                  
  Dependant:                  
  Dependant:                  
  Dependant:                  

  *Address:
  Address2:

    *City:           *State:     *Zip:
    *Country: 

   *Home Phone:
                                   111-111-1111
      Fax Phone:      
     Cell Phone:      
   

   *Policy Type

                Individual                                            $     $ 240.00      (Annual MASA membership fee)
                     
                Family                                                  $     $ 360.00      (Annual MASA membership fee)

                                          
                     Additional Fee:                                     
                      Initiation  Fee                                       +   $60.00     (First year only.)
                 ---------------------------------------------------------------------------------

                           Total Amount Due                     $     

    Please enter your payment amount and select your method of payment.

     * Authorized Payment Amount:   $

        *Card #        *Exp:
                                 9999999999999999                             mm/yy

     [MasterCard]         [Visa]      [American Express]     [Discover Card]

     Automatically renew my coverage each year
 

     Note: All pre-existing conditions are covered after only 90 days.