Test form Signups
| Status | Active |
|---|---|
| Misc Member Notes | [email protected], member called to update EM, was spelled incorrectly. Sent her a manual EM. 09/17/26 MT |
| Membership Type | Individual Plan ($99.95) |
| Are you renewing your plan? | No |
| Your Name | Melissa Waite |
| Email hidden; Javascript is required. | |
| Phone | (607) 857-5829 |
| Date of Birth | 03/27/1957 |
| Enter Office Code | DC1295 |
| Address | 110 Verona St Elmira Heights, NY 14903 Map It |
| Payment Method | Credit Card |
| Credit Card | visa XXXXXXXXXXXX4872 |
| 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 | 09/17/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 10/17/2027 |
| Membership ID Number | 1789661392 |
| 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. *** |
