Test form Signups
| Status | Future |
|---|---|
| Misc Member Notes | Member called to make sure we got check. 09/17/25 MT |
| Membership Type | Family Plan ($139.95) |
| 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. | 1757520747 |
| Your Name | Thomas Allardyce |
| Phone | (570) 655-1962 |
| Date of Birth | 01/03/1941 |
| List Family Members | Ann Marie |
| Referred by or Referral Code | ExMail 09/29/26 |
| Enter Office Code | A13786 |
| Administrative Code | 10DOLLARS |
| Address | 28 Ambrose St Pittston, PA 18640 Map It |
| Payment Method | Check |
| Payment Received | Paid |
| Total | $129.95 |
| 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 | 1790698501 |
| 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. *** |
