Test form Signups
| Status | Future |
|---|---|
| Misc Member Notes | paid by echeck info on fax. 08/29/24 JC CC field not available on SU form, processed in Stripe. 09/22/26 MT |
| 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. | 1759759501 |
| Your Name | Marlin Kirshenbaum |
| Email hidden; Javascript is required. | |
| Phone | (847) 436-1204 |
| Date of Birth | 03/20/1951 |
| Referred by or Referral Code | Fax 12/20/19, ExFax 08/29/24 |
| Enter Office Code | 29384 |
| Address | 8256 Turtle Creek Circle Las Vegas, NV 89113 Map It |
| Payment Method | Check |
| Payment Received | Paid |
| Total | $99.95 |
| Go Green | Paperless Option | yes |
| 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 | 11/07/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 12/07/2027 |
| Membership ID Number | 1790110036 |
| Past Plan Information | this probably isn't needed there should already be additional entries |
| Resend Sign Up Email | 7 |
| HTML Block | ***After clicking submit please wait 10 seconds for the form to process. Thank you. *** |
