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Primecard® ... It's About Choice!
Phone: 1-800-444-8872
E-mail: support@primecard.com

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Primecard Membership Application
(New Members Only)

FREE 6-month membership
(Save Up to 50% On Your Purchases)
Members will receive bi-monthly directories, newsletters and special offers.

Complete the form below and submit. Or to apply by mail or fax, click here to download the form in PDF format and send it to the address or fax number listed on the form. Or to apply by phone, call Customer Service, 1-800-444-8872.

Applicant Information

Optional Referral Code:
(Enter referral code if applicable, to activate special offer or promotion)

First Name:

MI:

Last Name:

SSN: - -

Date of Birth: - -

Email:

Home Telephone:() - -

Mailing Address: -

City: State: ZIP/Postal Code:

Mother's Maiden Name:

Employer:

Work Telephone:() - -

Additional User (Optional)

First Name:

MI:

Last Name:

Social Security # of Add'l User: - -

Monthly Credit Card Payment Authorization

Card Type:

Credit Card #:

Expiration Date:

By checking this box, I state that I have read, and agree to, Primecard 's Account Application Terms and Conditions. Upon credit approval, you should receive your Primecard card within 10 business days.