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-3283 SECTION GA S GROUP APPLICATION FOR BLUESELECT VOLUNTARY GROUP DENTAL CONTRACT Application is hereby made TO: Blue Cross and Blue Shield of Oklahoma, Home Offices: 1215 South Boulder, P.O. Box 3283, Tulsa, Oklahoma 74102-3283 (herein called the "Plan") BY: APPLICANT (BUSINESS NAME) CONTACT AT FIRM PHONE ADDRESS OF FIRM CITY AND STATE G Corporation ZIP CODE G Proprietorship G Partnership G Other (specify) IT IS UNDERSTOOD AND AGREED THAT NO AGENT HAS THE AUTHORITY TO ALTER OR AMEN.

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