First Name:	Middle Initial:
Last Name:
Date of Birth:	/ / ex. 01/20/1970
SSN	- -
Mailing Address:
City	State
Zip Code:	-
Home Phone:	--
Work Phone:	-- Ext.
Email Address:	Do you wish to receive periodic updates via email about your membership? Your privacy is a priority with us! PPLSI will not sell your email address or personal information of any kind to third party vendors Yes No
Spouse First Name:
Spouse Last Name:
How many dependents do you have? 0 1 2 3 4 5 6 7 8 9

Dependents
	First Name	Last Name	Date of Birth ex.01/20/1970
1:			/ /
2:			/ /
3:			/ /
4:			/ /
5:			/ /
6:			/ /
7:			/ /
8:			/ /
9:			/ /

I wish to pay by credit card until I revoke this authorization in writing. I realize my first charge will include $10 to cover my enrollment fee where applicable.
Credit Card
Credit Card No.:
Cardholder's Name:
Card Type:	Visa MasterCard Discover American Express
Expiration Date:	/ ex. 01/2008
Your account will be drafted each month on or about the effective date of your membership.