HENRY SCHEIN ACCOUNT NUMBER:
(NOTE: If you would like your credit applied to an group practice/office account, check the box at the bottom of the form.)
DESIGNATED OFFICE SECTION (in lieu of personal acceptance of grant):
Only complete this section if you are assigning your credit to a group/practice Henry Schein account.
ASSIGN TO GROUP/PRACTICE ACCOUNT: I do not personally incur my practice expenses. I would like my $1,000 grant from DeltaDental of Michigan, Ohio, and Indiana to which I understand that I am entitled to insteadbe paid as a grant to the eligible practice account listed above as the DesignatedOffice to defer the costs of care for my patients. I understand that, by making thisrequest, I will no longer be eligible to personally receive the $1,000 grant and once Icheck this box and submit this form, the $1,000 grant, if made, will be paid only to theDesignated Office account indicated above (to the extent it is deemed eligible). I waiveany and all personal rights or entitlement to this grant.
REQUIRED ACKNOWLEDGMENT: By checking this box, I acknowledge that I am the person whose name appears within this document and I agree with the terms and conditions herein.