Test form Signups
| Status | Future |
|---|---|
| Misc Member Notes | GiveFreeGetFree recipient, 1 free month added for referred by Lois Misko 1649785107. EM sent. 06/15/22 JC Adjusted dates/EM count, resent. 07/07/25 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. | DC1751675268 |
| Your Name | Donna Jones |
| Email hidden; Javascript is required. | |
| Phone | (412) 429-0711 |
| Date of Birth | 10/02/1947 |
| Referred by or Referral Code | Lois Misko 1649785107 done. |
| Address | 20 Sigrid Dr. Carnegie, PA 15106 Map It |
| Payment Method | Credit Card |
| Credit Card | discover XXXXXXXXXXXX1548 |
| Total | $99.95 |
| 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 | 11/19/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 12/19/2027 |
| Membership ID Number | 1790519728 |
| Past Plan Information | this probably isn't needed there should already be additional entries |
| Resend Sign Up Email | 6 |
| HTML Block | ***After clicking submit please wait 10 seconds for the form to process. Thank you. *** |
