Test form Signups
| Status | Active |
|---|---|
| Misc Member Notes | They sent EM to update EM to [email protected], but when they renewed, EM entered was [email protected]. Updated in DCmember. 4/12/2022 MT GFGF for Denise Letz DC1721238740 7/17/24 EK |
| 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. | 1757520894 |
| Your Name | Robert Fischer |
| Email hidden; Javascript is required. | |
| Phone | (330) 607-7507 |
| Date of Birth | 01/16/1947 |
| Referred by or Referral Code | ExMail 09/24/26 |
| Enter Office Code | GM4541 |
| Administrative Code | 10DOLLARS |
| Address | 1046 N Jefferson St, #105 Medina, OH 44256 Map It |
| Payment Method | Check |
| Payment Received | Paid |
| Total | $89.95 |
| 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 | 1790267102 |
| 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. *** |
