Test form Signups
| Status | Active |
|---|---|
| Misc Member Notes | GFGF recipient, 1mo added 07/17/25 MT Member called bc auto EM sent w/ original exp date, adjusted date in mailchimp, resent. 08/17/26 MT |
| Membership Type | Individual Plan ($99.95) |
| 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. | DC1752782504 |
| Your Name | Victoria Bauer |
| Email hidden; Javascript is required. | |
| Phone | (513) 260-0007 |
| Date of Birth | 10/13/1952 |
| Referred by or Referral Code | Ilene Stanko 1723134612-member done |
| Address | 5366 Hidden Pines Ct Brighton, MI 48116 Map It |
| Payment Method | Credit Card |
| Credit Card | discover XXXXXXXXXXXX3252 |
| Total | $99.95 |
| 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 | 09/18/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 10/18/2027 |
| Membership ID Number | 1789592641 |
| Past Plan Information | this probably isn't needed there should already be additional entries |
| Resend Sign Up Email | 3 |
| HTML Block | ***After clicking submit please wait 10 seconds for the form to process. Thank you. *** |
