Test form Signups
| Status | Future |
|---|---|
| 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. | DC1757457982 |
| Your Name | Marie Barber |
| Email hidden; Javascript is required. | |
| Phone | (570) 640-4207 |
| Date of Birth | 06/19/1965 |
| Referred by or Referral Code | Mail 10/23/23 |
| Enter Office Code | A12522 |
| Address | 244 West Main St Girardville, PA 17935 Map It |
| Payment Method | Credit Card |
| Credit Card | visa XXXXXXXXXXXX4535 |
| 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 | 01/26/2027 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 02/26/2028 |
| Membership ID Number | 1790534143 |
| 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. *** |
