Test form Signups
| Status | Active |
|---|---|
| Misc Member Notes | Member's computer accidentally filled in his mother's contact info (Elza Jones) for renewal. Jon spoke w/ over chat, updated 4/19/22 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. | 1748346650 |
| Your Name | Gary Leftwich |
| Email hidden; Javascript is required. | |
| Phone | (276) 620-4451 |
| Date of Birth | 02/22/1950 |
| Dentist Last Name | Ney (RG2551) |
| Address | 1136 Oak Ridge Rd. Cana, VA 24317 Map It |
| Payment Method | Credit Card |
| Credit Card | mastercard XXXXXXXXXXXX9675 |
| 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 | 09/29/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 10/29/2027 |
| Membership ID Number | 1790454166 |
| Past Plan Information | this probably isn't needed there should already be additional entries |
| Resend Sign Up Email | 9 |
| HTML Block | ***After clicking submit please wait 10 seconds for the form to process. Thank you. *** |
