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MEMBER NAME

First     Middle     Last
Male
Female
 

ADDRESS


Street

 

 



City       State      Zip

 

DATE OF BIRTH
AGE
TELEPHONE
REP ID

MEMBER CHOICES (CHECK ONE)

 

ELITE
Up to 200 Days/1000 Hours
NETWORK – 500 Hours: Network Home Care Services
FREEDOM – 500 Hours: Companion Home Care Service
 

ULTRA  
Up to 150 Days/750 Hours
NETWORK – 375 Hours: Network Home Care Services
FREEDOM – 375 Hours: Companion Home Care Service
 

PREFERRED
Up to 100 Days/500 Hours
NETWORK – 250 Hours: Network Home Care Services
FREEDOM – 250 Hours: Companion Home Care Service

STANDARD
Up to 60 Days/300 Hours
NETWORK – 150 Hours: Network Home Care Services
FREEDOM – 150 Hours: Companion Home Care Service
 

BASIC
Up to 30 Days/150 Hours
NETWORK – 75 Hours: Network Home Care Services
FREEDOM – 75 Hours: Companion Home Care Service
 

 

Member Initials

All memberships include NETWORK Home Care Services for up to 5 Hours a Day/5 Days a Week & FREEDOM Home Care Companion Services for up to 8 Hours a Day/5 Days a Week.

The representative explained the cancellation procedure in full. I have read and understand the 10-day Free Look, the signed cancellation letter from member, and True Freedom’s mailing address as well as the membership terms & conditions. True Freedom II Plans are Service Contracts, NOT Insurance.

Member Initials

PAYMENT (CHECK ONE)

Monthly Bank Plan
Semi-Annual
Annual
 

Amount Collected

Check Number

Membership Renewal Options:

Monthly Bank Plan
Semi-Annual Invoice 
Annual Invoice

Member Initials

 

I’ve reviewed & agree to the Terms & Conditions  

    Download Application & Sign