Test form Signups
| Status | Active |
|---|---|
| Misc Member Notes | Requested that we send out membership cards 10/7/19 KS member called to add Leanne Candeloro to active plan & renew 3/16/21 EK Veda called in, said she would like a card for her adult daughter that lives with them and is on the plan. added to resend list. 03/29/21 JC Member requested another set of cards for Leanne. Added to resend master 3/28/22 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. | 1753211344 |
| Your Name | Veda Candeloro |
| Email hidden; Javascript is required. | |
| Phone | (702) 505-4629 |
| Date of Birth | 10/22/1943 |
| List Family Members | Richard, Leanne |
| Referred by or Referral Code | ExMail 07/22/2025, ExMail 09/24/26 |
| Enter Office Code | 29384 |
| Address | 4963 Momenti St Las Vegas, NV 89135 Map It |
| Payment Method | Credit Card |
| Credit Card | visa XXXXXXXXXXXX0119 |
| 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 | 10/08/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 11/08/2027 |
| Membership ID Number | 1790267566 |
| 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. *** |
