Dental Enrollment Form

                                   Dental Enrollment Form
                                                                  Print out and Complete
                                   Mail or Fax to: Dental Plans, Inc./ Federal Employee Benefits
          250 Langley Dr, Ste. 1315 ~ Lawrenceville , GA 30045-6932
   Ph.(770)963-3939 or (800)578-2082 ~ Fax (770)963-6126 or (888)264-6975

                Product underwritten by The United States Life Insurance Company in the City of New York

1. Name of Employer / Association ___________________________________________________________
2. Employee's / Member full name _______________________________________ SS#_____ _____ _____
3. Home Address_______________________________________________________________________
City _____________________________________________________ State ______ Zip ____________
Home Phone_______________________ Work Phone __________________________ Ext.__________
E-Mail Address _______________________________________________________________________
--------DENTAL--------
Employee	* Date _________/________/_________
Spouse Children	____ Employee ____ Employee and Spouse ____ Employee and Child(ren) ____ Full Family
Name	Age	Date of Birth (mm/dd/yyyy)	Sex
EE
SP
CH
CH
CH
CH
CH

Date Signed:____________ Signature of Employee /Member_________________________________