Test form Signups
| Status | Future |
|---|---|
| Misc Member Notes | Member wondered if she can get cleaning/xrays early. Told her she can use plan as often as she'd like w/in mship. 07/11/2022 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. | 1758212934 |
| Your Name | Lois B Henry |
| Email hidden; Javascript is required. | |
| Phone | (763) 515-3560 |
| Date of Birth | 12/25/1946 |
| Referred by or Referral Code | ExMail 10-28-16 |
| Address | 7527 Large Ave NE Otsego, MN 55301 Map It |
| Payment Method | Credit Card |
| Credit Card | visa XXXXXXXXXXXX7364 |
| 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 | 11/12/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 12/12/2027 |
| Membership ID Number | 1790611558 |
| 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. *** |
