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Step 1 of 3:
Please completely fill out the following form to apply for UltraCare Rx.

First Name:
Last Name:
Gender:
Social Security Number:
xxx-xx-xxxx
Date of Birth:
MM/DD/YYYY
Street Address:
Apt. / Suite #:
City:
State:
Zip Code:
Phone Number:
xxx-xxx-xxxx
EMail Address:
Plan Type:
Mail Order Option:   Yes, I would like to take advantage of a strong U.S.
Dollar and low cost brand name prescription drugs from
Canada to save 50% - 75% for only an additional $5 per month!
( details )