Test form Signups
| Status | Active |
|---|---|
| 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. | 1753966022 |
| Your Name | Carol Paul |
| Phone | (570) 874-0618 |
| Date of Birth | 09/27/1941 |
| Referred by or Referral Code | ExMail 5/10/2022, ExMail 07/01/24, ExMail 09/24/26 |
| Enter Office Code | A12522 |
| Address | 974 Fountain St Ashland, PA 17921 Map It |
| Payment Method | Check |
| Payment Received | Paid |
| 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 | 10/17/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 11/17/2027 |
| Membership ID Number | 1790265768 |
| 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. *** |
