Paradigm Solutions Group

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Paradigm HEP Card

Enter all necessary information and click "Submit" at the end of this form to enroll

Primary Member Information - (Please complete all information)

First Name	Last Name M.I.
Address
City
State
Zip Code	-
Telephone	- -
Email Address

Member Registration - (As you would like the names to appear on the wallet ID cards.)

First Name Last Name SSN DOB

Primary Member   / /

Member   / /
Member   / /
Member   / /
Member   / /
Member   / /
Member   / /
Member   / /
Member   / /
Member   / /
Member   / /

Representative Information

Full Name

Company Name

ID Number

Payment Information

Annually Monthly

HEP Basic $72.00 $6.00
HEP Gold $96.00 $8.00

HEP Platinum $132.00 $11.00

Payment Type

Credit Card

Bank Draft

Type Routing Nbr

Card Nbr Account Nbr

Expires

Exact Name on Card