Mercy Choice Membership Application

The Mercy Choice program is designed to promote good health and add quality to your life. There is absolutely no cost to join and all services are complimentary or offered at discounted prices.

Name:	First	Middle Initial	Last
Social Security #:  Sex:  Female Male   Marital Status:  Married Single Widowed Divorced Unknown
Address:
City:    State:  Arkansas Oklahoma ______________ Alabama Alaska Arizona Arkansas California Colorado Connecticut Deleware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Lousiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Other  Zip:
Birth Date (MM/DD/YYYY):
Phone:

Nearest Relative:
	Name:
	Address:
	City:    State:  Arkansas Oklahoma ______________ Alabama Alaska Arizona Arkansas California Colorado Connecticut Deleware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Lousiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Other  Zip:
	Phone:
Spouse's Name (if applicable):
	Name:
	Phone (If different):
If you have a relative or friend who would like to join Mercy Choice, we will be happy to send them an application:
	Name:
	Address:
	City:    State:  Arkansas Oklahoma ______________ Alabama Alaska Arizona Arkansas California Colorado Connecticut Deleware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Lousiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Other  Zip: