Test form Signups
| Status | Active |
|---|---|
| Misc Member Notes | Member complained about $10 fee, said it's very misleading. I explained, said can waive it this time. 09/16/26 MT |
| Membership Type | Family Plan ($139.95) |
| Are you renewing your plan? | Yes |
| Please enter your current membership ID# here. You can find this in your renewal email or on your current membership card. | 1757015672 |
| Your Name | George Lininger |
| Email hidden; Javascript is required. | |
| Phone | (717) 414-9106 |
| Date of Birth | 04/30/1956 |
| List Family Members | Leslie |
| Enter Office Code | DC1101 |
| Administrative Code | 10DOLLARS |
| Address | 10262 Candura Drive Waynesboro, PA 17268 Map It |
| Payment Method | Credit Card |
| Credit Card | discover XXXXXXXXXXXX8762 |
| Total | $129.95 |
| Go Green | Paperless Option | not |
| Terms |  I have read the Terms and Conditions and wish to purchase the Discount Medical Plan. |
| Plan Information | |
| Newest Membership: Programmatically pick Plan Start Date Based on either new plan or their ID number here | 10/05/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 11/05/2027 |
| Membership ID Number | 1789587547 |
| Past Plan Information | this probably isn't needed there should already be additional entries |
| Resend Sign Up Email | 2 |
| HTML Block | ***After clicking submit please wait 10 seconds for the form to process. Thank you. *** |
