Test form Signups
| Status | Active |
|---|---|
| Misc Member Notes | No ID used when renewing, adjusted info. 5/24/2022 MT Member called in as they got auto call, told him to disregard, added space in primary. 08/09/24 MT |
| 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. | 1756224006 |
| Your Name | Mark Smitek |
| Email hidden; Javascript is required. | |
| Phone | (216) 659-0903 |
| Date of Birth | 06/06/1958 |
| Enter Office Code | GM4034 |
| Address | 700 Brick Mill Run #505 Westlake, OH 44145 Map It |
| Payment Method | Credit Card |
| Credit Card | visa XXXXXXXXXXXX1867 |
| 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 | 10/19/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 11/19/2027 |
| Membership ID Number | 1790297005 |
| 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. *** |
