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TRS-ActiveCare Supplies for Benefits Administrators



Name
District
TRS Reporting Number
Mailing Address (No P.O. Boxes)
City
State ( i.e. TX)
Zip Code  
Phone ( e.g. 123-456-1234)
Phone Extension ( e.g. 12 or x12)
Email Address

Select the supplies you need to order and indicate quantity.
Enrollment Guide Quantity
English/Spanish 2012–2013 version *Available after 04/16/12*  
English/Spanish 2011–2012 version  
 
Enrollment Application and Change Form Quantity
English (available in tablets of 50 apps; indicate number of tablets)  
Spanish (available in tablets of 25 apps; indicate number of tablets)  
 
Mailing Labels Quantity
Available in sheets of 6; please indicate number of sheets  
 
Other — Please indicate name of item and quantity Quantity
    
    
    
 
Special Instructions

Select the "Submit" button when you've completed this form and your supplies will be shipped within 5 to 7 business days. Thank you.