Test form Signups

StatusActive
Membership TypeIndividual Plan ($99.95)
Are you renewing your plan?No
Your NameRoberto Castillo
Phone(831) 676-1258
Date of Birth12/14/1984
Enter Office CodeRG6131
Address1521 Mesquite Dr
Salinas, CA 93905
Map It
Payment MethodCredit Card
Credit Cardvisa
XXXXXXXXXXXX8937
Total$99.95
Go Green | Paperless Optionnot
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 here09/16/2026
Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here10/16/2027
Membership ID Number1789597062
Past Plan Informationthis probably isn't needed there should already be additional entries
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