Test form Signups
| Status | Active |
|---|---|
| Misc Member Notes | Updated address to match renewal. 03/24/2025 EK Is a renewal, adjusted EM count. 09/25/26 MT |
| Membership Type | Individual Plan ($99.95) |
| Are you renewing your plan? | No |
| Your Name | Donna Amado |
| Email hidden; Javascript is required. | |
| Phone | (916) 782-7347 |
| Date of Birth | 07/25/1951 |
| Enter Office Code | 6903 |
| Address | 5098 Foothills Blvd Suite 3-141 Roseville, CA 95747 Map It |
| Payment Method | Credit Card |
| Credit Card | discover XXXXXXXXXXXX9134 |
| 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 | 09/25/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 10/25/2027 |
| Membership ID Number | 1790348206 |
| Past Plan Information | this probably isn't needed there should already be additional entries |
| Resend Sign Up Email | 4 |
| HTML Block | ***After clicking submit please wait 10 seconds for the form to process. Thank you. *** |
