Test form Signups
| Status | Active |
|---|---|
| Misc Member Notes | Renewal A23471, Member’s plan history is gone in DC member as he hasn’t been a member since 2019-2020, but I found him in my emails. 9/24/26 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. | 41326907705 |
| Your Name | Kyle Strube |
| Email hidden; Javascript is required. | |
| Phone | (404) 222-9269 |
| Date of Birth | 08/04/1986 |
| Enter Office Code | A23471 |
| Address | 536 Butler St Windermere, FL 34786 Map It |
| Payment Method | Credit Card |
| Credit Card | mastercard XXXXXXXXXXXX0866 |
| Total | $99.95 |
| Go Green | Paperless Option | yes |
| 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 | 1790276643 |
| Past Plan Information | this probably isn't needed there should already be additional entries |
| Resend Sign Up Email | 1 |
| HTML Block | ***After clicking submit please wait 10 seconds for the form to process. Thank you. *** |
