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Print Form ENROLLMENT FORM FOR NEW PARTICIPANTS Prescription Drug Program Provided by: Fields with an * asterisk are required. Employer Name* Employee Name middle first* Date of Birth* Month Day last*
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How to fill out month day month day:
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Start by writing the current month in numerical format. For example, if it is January, write "01" for January.
02
Next, write the current day in numerical format. For instance, if it is the 15th day of the month, write "15".
03
After that, write the month you are referring to again, but this time in word format. If it is January, write "January".
04
Finally, write the day you are referring to in word format. For example, if it is the 20th day of the month, write "twenty".
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