Test form Signups

By Baljinder Singh On February 26, 2026 0 Comment

Status	Active
Misc Member Notes	Adjusted EM count, resent. 03/29/2023 MT Member has a family member that needs the plan in June, told her best option would be to end this ind plan early and start new fam plan. She will call back. 6/2/26 EK Is a renewal, adjusted EM count. 09/21/26 MT
Membership Type	Family Plan ($139.95)
Are you renewing your plan?	No
Your Name	Marga Alexander
Email	Email hidden; Javascript is required.
Phone	(586) 255-3506
Date of Birth	10/04/1985
List Family Members	Josef, Levi, Nicolas
Enter Office Code	A22511
Address	73112 Windmill Dr Bruce Twp, MI 48065 Map It
Payment Method	Credit Card
Credit Card	visa XXXXXXXXXXXX4877
Total	$139.95
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	09/21/2026
Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here	10/21/2027
Membership ID Number	1790001187
Past Plan Information	this probably isn't needed there should already be additional entries
Resend Sign Up Email	4
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