Test form Signups

By Baljinder Singh On February 26, 2026 0 Comment

Status	Active
Misc Member Notes	Corrected dates, resent EM. 04/02/21 JC How do they want to pay? LVM 9/24/26 EK EM sent, removed from Mcard list 9/29/26 EK Member's daughter called in with payment, paid by Echeck, added to mcard resend list. 10/1/26 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.	1754923335
Your Name	Robert Bryer
Email	Email hidden; Javascript is required.
Phone	(330) 714-9986
Date of Birth	09/03/1936
List Family Members	Melba Jean
Enter Office Code	GM4541
Address	68 Cambrian Dr Tallmadge, OH 44278-2313 Map It
Payment Method	Check
Payment Received	Paid
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	10/09/2026
Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here	11/09/2027
Membership ID Number	1790203289
Past Plan Information	this probably isn't needed there should already be additional entries
Resend Sign Up Email	8
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