OTC Benefits Card Registration Form

OTC Benefits Card Registration Form
Register to access your OTC benefits card. Please complete all eligibility and registration details below.
Full Name
First NameLast Name
Date of Birth
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Gender
Member ID or Policy Number
Are you currently enrolled in an eligible OTC benefits program?
Primary Language
Preferred Contact Method
Please provide any additional information relevant to your registration
Should be Empty: