Louisiana Dental Plan Credit Card Payment Application

Welcome to the Louisiana Dental Plan Credit Card Payment System.
Simply complete this form, agree to the terms of enrollment, and click the "Pay with Card" button.

Monthly Payment
Individual	Family Plan
$6.00	$10.00
There is a one time enrollment fee of $20.00 which will be drafted from your bank account.

Please complete all of the following information.

Date:

Name:

Address:

City: State: Zip:

Email Address:

Home Phone: Work Phone:

Employer:

Date of Birth:

Plan Type (Monthly Fee):

Note: The following section should only be filled out if you desire coverage for dependents

Spouse/Children/Dependents	Sex	Date of Birth

How did you hear about us?

I AGREE to ALL Louisiana Dental Plan terms and conditions as listed below.

I hereby authorize Louisiana Dental Plan to charge my card for the $20.00 enrollment fee and the monthly payment. Recurring payments will be processed until cancellation notice is provided.