Test form Signups
| Status | Future |
|---|---|
| Misc Member Notes | adjuste dates. resent email. 06/22/23 JC |
| 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. | 1755877801 |
| Your Name | FRANCES HOTOCHIN |
| Email hidden; Javascript is required. | |
| Phone | (724) 483-3352 |
| Date of Birth | 09/18/1946 |
| List Family Members | George |
| Address | 8 Albert Avenue Monongahela, PA 15063 Map It |
| Payment Method | Credit Card |
| Credit Card | visa XXXXXXXXXXXX7153 |
| 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 | 1790016034 |
| Past Plan Information | this probably isn't needed there should already be additional entries |
| Resend Sign Up Email | 9 |
| HTML Block | ***After clicking submit please wait 10 seconds for the form to process. Thank you. *** |
