Step 1: Select Payments
Step 2: Review and Submit
Step 3: Confirmation and Receipt
Step 1: Select Payments

Please complete the registration and payment information below. When finished, click “Continue” and you will be asked to review the information for accuracy before payment is processed. Citizens of CRFR pay $65. per benefit year for the entire household.

Membership benefits apply to residents served by CRFR and are valid for the entire benefit period (11/1 – 10/31) if registering during the open enrollment.

If registering outside of open enrollment, benefits are valid after deposit of payment (plus one business day) through Oct 31st of the current benefit period.

Note: * indicates a required field.

My Bills
Payment Type: *
Amount: *

Primary Member
FirstName: *
Middle Initial:
LastName: *
Date of Birth: *
Home Address: *
City: *
State: *
Zip: *
Phone Number: *
Email Address: *

Mailing address different than your home address?
Mailing Address:
City:
State:
Zip:

Other Household Members
First Name:
Middle Initial:
Last Name:
Date of Birth:
First Name:
Middle Initial:
Last Name:
Date of Birth:
First Name:
Middle Initial:
Last Name:
Date of Birth:
First Name:
Middle Initial:
Last Name:
Date of Birth:
First Name:
Middle Initial:
Last Name:
Date of Birth:
First Name:
Middle Initial:
Last Name:
Date of Birth:
First Name:
Middle Initial:
Last Name:
Date of Birth:

Cardholder Information
First Name: *
Last Name: *
Address Line 1: *
Address Line 2:
City: *
State: *
Zip Code: *
Phone Number: *
Email Address: *

Payment Information
Payment Method: *
Card Number: *
Expiration Date: * (in mm/yy format)