Test form Signups

By Baljinder Singh On February 26, 2026 0 Comment

Status	Active
Misc Member Notes	Adjusted dates, resent EM. 07/16/21 JC 2month Exp returned, Attempted not known, UTF. Called & someone else answered. Said Lynn not there & to call back another time.10/27/22 EK A different person answered, said Lynn not avail & to call back later 11/1/22 EK Member called in to renew, said address was correct 11/1/22 EK updated tel# to match renewal. 12/04/23 JC
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.	1753129594
Your Name	Lynn Vander Pluym
Email	Email hidden; Javascript is required.
Phone	(314) 585-2350
Date of Birth	10/16/1970
Referred by or Referral Code	ExMail 12/04/23
Enter Office Code	A20830
Address	325 Francisca Drive Florissant, MO 63031 Map It
Payment Method	Credit Card
Credit Card	visa XXXXXXXXXXXX1695
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	09/24/2026
Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here	10/24/2027
Membership ID Number	1790256114
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. *

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