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Benefits for Chamber of Commerce Members
Benefits for Chamber of Commerce Members
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MedPerks Video
MedPerks Card
MedPerks Enrollment
Employee Benefit
MedPerks Enrollment
MedPerks Individual Enrollment Form
First Name:
Last Name:
Address:
City:
State:
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip Code:
(5 digits)
Daytime Phone:
Email:
Date of Birth:
Sex:
Male
Female
Marital Status:
Married
Single
Chamber Affiliation:
Dependent Members
Dependent #1 Name:
Date of Birth:
Dependent #2 Name:
Date of Birth:
Dependent #3 Name:
Date of Birth:
Dependent #4 Name:
Date of Birth:
Payment Options
Price per Quarter $20.85 or Annual $83.40
VISA
MasterCard
American Express
DiscoverCard
Name on Credit Card:
Credit Card Number:
Expiration Date:
Security Code (last 3 numbers on back):
Amount:
Additional Information:
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