Test form Signups
| Status | Future |
|---|---|
| Misc Member Notes | GFGF for Alexandria Yoby DC1687968187 6/28/23 EK |
| Membership Type | Family Plan ($139.95) |
| 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. | 1750014203 |
| Your Name | Dale Haynes |
| Email hidden; Javascript is required. | |
| Phone | (440) 714-5929 |
| Date of Birth | 10/21/1950 |
| List Family Members | Susan |
| Referred by or Referral Code | ExMail 08/02/24 |
| Enter Office Code | GM1008 |
| Address | 319 West Main Street South Amherst, OH 44001 Map It |
| Payment Method | Credit Card |
| Credit Card | mastercard XXXXXXXXXXXX9817 |
| 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 | 11/12/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 12/12/2027 |
| Membership ID Number | 1790014900 |
| Past Plan Information | this probably isn't needed there should already be additional entries |
| Resend Sign Up Email | 5 |
| HTML Block | ***After clicking submit please wait 10 seconds for the form to process. Thank you. *** |
