Hotel Pharmacy Vermont Yankee Employee Insurance Charge Account Application
Covered Employee Name:  ____________________________________	Social Security #:  _________________________
Dependents covered by this policy:
Name	Relationship to policy holder
1. ______________________________________	1. _______________________________
2. ______________________________________	2. _______________________________
3. ______________________________________	3. _______________________________
4. ______________________________________	4. _______________________________
Address: ____________________________________________________________
How long at this address: ______________________________
Home Phone: _____________________	Work Phone: _____________________
Local Charge Accounts: (Name, address, phone, & account #)
1. _________________________________________________________________________
2. _________________________________________________________________________
3. _________________________________________________________________________
Other Charge Accounts/Credit Cards: (Name, address, phone, & account #)
1. _________________________________________________________________________
2. _________________________________________________________________________
Bank Information
Name: ___________________________________________________________________
Address & Phone: _________________________________________________________
Account Type & Number: ___________________________________________________
Personal References: (Name, address, phone)
1. _________________________________________________________________________
2. _________________________________________________________________________
I give my permission for Hotel Pharmacy to receive credit information from the sources listed above, and to verify employment. I have received a copy of the terms of this account (from Hotel Pharmacy). I have read and understand the terms of this account, and agree to them.

Applicant Signature: ____________________________________

Date: ___________________