Test form Signups
| Status | Active |
|---|---|
| Misc Member Notes | GFGF Recipient 7/11/24 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. | 1753887810 |
| Your Name | Susan O'Donohue-Williams |
| Email hidden; Javascript is required. | |
| Phone | (313) 408-4817 |
| Date of Birth | 03/17/1948 |
| Referred by or Referral Code | Gregory Beckman DC1720728587 Done, ExMail 07/30/25, ExMail 09/29/26 |
| Address | 32621 5 Mile Rd Livonia, MI 48154 Map It |
| Payment Method | Check |
| Payment Received | Paid |
| 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 | 10/13/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 11/13/2027 |
| Membership ID Number | 1790697641 |
| Past Plan Information | this probably isn't needed there should already be additional entries |
| Resend Sign Up Email | 3 |
| HTML Block | ***After clicking submit please wait 10 seconds for the form to process. Thank you. *** |
