Test form Signups
| Status | Active |
|---|---|
| Misc Member Notes | Member called to see when his mcards were coming, told him still on the way. 09/19/25 MT member wanted receipt emailed. Done in Stripe [email protected] 9/22/26 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. | 1756995214 |
| Your Name | Henry Nolker |
| Phone | (410) 529-5976 |
| Date of Birth | 05/11/1943 |
| List Family Members | Joan |
| Enter Office Code | RG4844 |
| Address | 4215 Winter Ode Way Nottingham, MD 21236 Map It |
| Payment Method | Credit Card |
| Credit Card | visa XXXXXXXXXXXX1795 |
| 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 | 10/05/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 11/05/2027 |
| Membership ID Number | 1790092939 |
| 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. *** |
