Select Access*Monthly Access at $5 Per MonthTotal Due Today $0.00 Member Name* First Last Mailing Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email Address Telephone Number*Gender*Please SelectFemaleMaleDate of Birth*Payment Information* American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20212022202320242025202620272028202920302031203220332034203520362037203820392040 Expiration Date Security Code Cardholder Name Terms and Conditions* Customer authorizes Sociallity to charge their credit card or debit card the amount due for this program access activation Customer authorizes Sociallity to automatically charge their credit card or debit card the monthly access fees. Customer understands that this charge will automatically be made until such a time that Customer elects to cancel their access. Customer acknowledges and understands that they may cancel the program access at any time without penalty. Upon canceling their access, Sociallity will immediately discontinue charging the monthly access fee. Customer acknowledges, agrees to, and accepts the Sociallity Privacy Policy, the Sociallity Website Use Terms and Conditions, the Sociallity AccessNow Terms and Conditions, and the Sociallity Healthcare Coin Terms and Conditions. Customer acknowledges that they understand that none of the programs or services made available to them by Sociallity are Insurance products. The Sociallity AccessNow Program is designed to help manage out-of-pocket and self-pay deductible expenses and are in no way to be considered Insurance.