FORM FOR RPS TRANSACTION

I AM A HOLDER OF:

VISA MASTER CARD JCB AMERICAN EXPRESS

CARD NUMBER : - - - -
(Please indicate the 16-digit card number and the last 3-digit number at the back of the card)

EXPIRATION DATE OF CREDIT CARD (MM-YYYY): -

CARDHOLDER’S CONTACT DETAILS: ____________________________

MAXICARE BILLS FOR ENROLLMENT

MODE OF DUE DATE

NAME OF MEMBER MAXICARE ID NO.
PAYMENT

_______________________________
Signature of Cardholder over Printed
Name