Test form Signups
| Status | Active |
|---|---|
| Misc Member Notes | wants to renew with check. sent expire letter in mail 6-18-15 AK. Dennis Adler called us to let us know he paid the mailman $0.50 to have his mail received because there was postage due for his envelope. 7-21-15 AK. refunded $1 8-25-15 AK mad they paid for family plan then wife cant use it because they got insurance.... offered to waive $10 processing fee when they renew next fall for IND. 12/05/23 JC |
| 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. | 1754073634 |
| Your Name | DENNIS ADLER SR |
| Phone | (586) 321-2271 |
| Date of Birth | 09/22/1942 |
| Enter Office Code | DC1236 |
| Address | 18660 BROHL ST ROSEVILLE, MI 48066 Map It |
| Payment Method | Credit Card |
| Credit Card | visa XXXXXXXXXXXX4600 |
| 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 | 10/09/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 11/09/2027 |
| Membership ID Number | 1789663564 |
| Past Plan Information | this probably isn't needed there should already be additional entries |
| Resend Sign Up Email | 8 |
| HTML Block | ***After clicking submit please wait 10 seconds for the form to process. Thank you. *** |
