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Membership Application

Independent Associate

Independent Associate

Personal Information

First Name:

Rhonda C

Last Name:

Potter

Date Of Birth:

03/17/1969

SSN:

245433663

Mailing Address:

3112 Maury Street

Charlotte, NC 28208-3929


Home Phone:

704-236-8324

Email Address:

rcpotter69@att.net

Email updates:

YES

Dependent Information

Number of Dependents:

2

# First Name Last Name Date of Birth 1 Kenneth Potter 06/22/1986 2 Alisha Potter 04/22/1993

Dependent #

First Name

Last Name

Date of Birth

1

Kenneth

Potter

06/22/1986

2

Alisha

Potter

04/22/1993

Payment Information

Payment Type:

Credit Card

Card Holder:

Rhonda Potter

Billing Address:

3112 Maury Street
Charlotte, NC. 28208

Card Number:

************8940

Card Type:

VISA

Draft Frequency:

monthly


Plan Information

Plan Type:

Standard Family Plan

Legal Shield Rider:

YES

Website Information

Login Name:

rcpotter


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