Test form Signups
| Status | Active |
|---|---|
| Misc Member Notes | Upgrd to fam pln: Thomas 1-23-18 SS ExMail 2/4/19, ExMail 1/31/2020, ExMail 06/26/2024, ExMail 07/25/25, |
| 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. | 1753465216 |
| Your Name | Janet Cummings |
| Email hidden; Javascript is required. | |
| Phone | (248) 860-5533 |
| Date of Birth | 02/25/1946 |
| Referred by or Referral Code | ExMail 09/29/26 |
| Enter Office Code | A21512 |
| Address | 3361 Westwind Dr. Commerce Charter Twp., MI 48390 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 | 09/30/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 10/30/2027 |
| Membership ID Number | 1790697946 |
| 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. *** |
