Test form Signups
| Status | Future |
|---|---|
| Misc Member Notes | Fax 3-2-18, ExMail 2/25/19, ExMail 03/19/20, ExMail 4/20/21, ExMail 05/31/22, ExMail 06/21/23, ExMail 07/23/2024, ExMail 08/25/2025, |
| 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. | 1756140659 |
| Your Name | William Jones |
| Email hidden; Javascript is required. | |
| Phone | (203) 395-8273 |
| Date of Birth | 02/15/1950 |
| Referred by or Referral Code | ExMail 09/29/26 |
| Enter Office Code | 11788 |
| Address | 1038 Johnson Rd Woodbridge, CT 6525 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 | 11/09/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 12/09/2027 |
| Membership ID Number | 1790698176 |
| 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. *** |
