Test form Signups
| Status | Active |
|---|---|
| Misc Member Notes | Covid Exp Letter returned, was sent by accident due to different address 7/7/20 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. | 1753887618 |
| Your Name | Kathryn L Lee |
| Email hidden; Javascript is required. | |
| Phone | (321) 626-0746 |
| Date of Birth | 03/05/1954 |
| List Family Members | James G Jr |
| Referred by or Referral Code | ExMail 09/24/26 |
| Enter Office Code | 46591 |
| Address | PO Box 1233 2458 Genoa Meadows Circle Genoa, NV 89411 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 | 10/11/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 11/11/2027 |
| Membership ID Number | 1790266585 |
| Past Plan Information | this probably isn't needed there should already be additional entries |
| Resend Sign Up Email | 8 |
| HTML Block | ***After clicking submit please wait 10 seconds for the form to process. Thank you. *** |
