Test form Signups
| Status | Active |
|---|---|
| Membership Type | Individual Plan ($99.95) |
| Are you renewing your plan? | No |
| Your Name | Darlene Loter |
| Email hidden; Javascript is required. | |
| Phone | (313) 633-9833 |
| Date of Birth | 10/14/1946 |
| Enter Office Code | A20829 |
| Address | 2710 Academy St Dearborn, MI 48124-4508 Map It |
| Payment Method | Credit Card |
| Credit Card | visa XXXXXXXXXXXX1390 |
| Total | $99.95 |
| 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 | 09/23/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 10/23/2027 |
| Membership ID Number | 1790198452 |
| Past Plan Information | this probably isn't needed there should already be additional entries |
| Resend Sign Up Email | 1 |
| HTML Block | ***After clicking submit please wait 10 seconds for the form to process. Thank you. *** |
