Auto Discounts and Services Program

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Call 1-800-276-5662 to speak to a "Customer Service Representative" for a membership, or you can fill out the form below.

Personal Information
*All bold fields are required
Name:
Spouse Name:
Street:
Apt./Suite:
City:
State:
Zip Code:
Daytime Phone:
Evening Phone:
Fax Number:
E-mail:

Programs and Options
Membership Cost:	$69.95 per year	All prices cover member & spouse. You may add additional family members under age 21 for $15.00 each. To add additional members, fill in their names in the next set of fields under Additional Members.
Number of Additional Members:
Total:

Additional Members

Please fill in the names of the additional family members to add to your plan. You should have the same number of additional names as you listed for "Additional Members" under Programs and Options. Additional Name: Additional Name: Additional Name: Additional Name:

Credit Card Information

Credit Card Type:   Choose Type Visa MasterCard Discover American Express Credit Card Number:   Expiration Date:   Name on Card: