Wellnessshield

WELLNESS SHIELD MEMBER SIGNUP

Sponsor Information

Your Wellness Shield Sponsor is:

* Sponsor Information:

New Members Information

* First Name:
* Last Name:
* Gender:	Male Female
* Date of Birth:	(mm/dd/yyyy)
* SSN #:	(9 digits - no spaces or dashes)
* Verify SSN #:
* Beneficiary:
* Employer:
* Address 1:
* Address 2:
* City, State, Zip:
* Business Phone	(xxx-xxx-xxxx)
* Home Phone:	(xxx-xxx-xxxx)
* Email:
* Verify Email:

Membership Access

* Password:
* Confirm Password:

Family Members

Please enroll my family members listed below (dependent children under the age of 19 or full-time student under the age of 25):
* Name of Spouse:
* Spouse Date of Birth:	(mm/dd/yyyy)
* Name of Child1:
* Child1 Date of Birth:	(mm/dd/yyyy)
* Name of Child2:
* Child2 Date of Birth:	(mm/dd/yyyy)
* Name of Child3:
* Child3 Date of Birth:	(mm/dd/yyyy)
* Name of Child4:
* Child4 Date of Birth:	(mm/dd/yyyy)
* Name of Child5:
* Child5 Date of Birth:	(mm/dd/yyyy)

The Wellness Shield Membership is backed by a full 30-day money-back guarantee of the first month's fees.

Wellness Shield Plan Month Membership Bank or Credit Card Draft
	$59.95
There is a one-time enrollment fee of $25.00 per family
	$25.00
Total:	$84.95

I understand the discount medical services in these plan(s) are not insurance.
	Please enroll me in The Wellness Shield Plan along with any association(s) I have chosen. I further understand that my membership may include certain supplemental insured benefits; that my membership is not a replacement for health insurance nor is it intending as a substitute for health insurance. Notice: If I enroll in the Accident Plan in the association named NACD, I hereby designate and appoint the Secretary of NACD as my proxy and my agent to act for as an association member for the purpose of attendance and voting at all meetings of members.

Payment Options

Please enroll me in the plans chosen in billing options above.

Initial Payment by: (check one)

Check

Credit Card

Bank Draft

Renewal/Billing: (check one)

Monthly Bank Draft

I hereby authorize Wellness Shield to debit my account in accordance with the billing options above. This authorization is to remain in effect until Wellness Shield receives written notification from me revoking it.

(if authorizing bank draft)

Bank Routing #:

Account #:

(if credit card processing)

Credit Card Billing Address

* Address 1:
* Address 2:
* City, State, Zip:

Billing Information

* Card Type:
* Card Number:	(13-16 characters, no spaces)
* Expiration:	/ (mm/yy)
* CC Verification #:	(see picture below)

Submit Form

Your card will be charged, $:

By selecting one of the enrollment options above, I certify that the information provided is accurate.  I understand that the failure to provide Wellness Shield Inc with a correct Social Security Number and Name may subject me to withholding on any payments Wellness Shield Inc may make to me and I may be subject to penalties imposed by Government Tax Agencies.
I agree that as an Wellness Shield Independent Agent, I am an independent contractor, and not an employee, agent, partner, legal representative, or franchisee of Wellness Shield Inc. I understand that I shall not be treated as an employee of Wellness Shield Inc for Federal or State Tax Purposes. I have carefully read and agree to comply with the Wellness Shield Policies and Procedures, the Wellness Shield Opportunity Overview, the Wellness Shield Disclaimer, the Wellness Shield Privacy Policy and the Wellness Shield Independent Agent Application and Agreement.. I understand that these documents may be amended from time to time, and I agree that any such amendment will apply to me. Notification of amendments shall be published in official Wellness Shield materials. The continuation of my Wellness Shield independent business or my acceptance of commissions, bonuses or other benefits shall constitute my acceptance of any and all amendments.
I understand that I have the right to terminate this Agreement at any time, with or without reason. I understand that such termination must be in writing. I understand and agree that Wellness Shield Inc may terminate this Agreement at any time, with or without reason, upon written notice to me.
I have read and Agree to all terms, policies, procedures, rules, regulations and plans that have been provided to me.

I AGREE

*Please press Submit Once. Any multiple attempts will cause multiple entries and possible charges. If you have any questions or encounter an error please contact us.