Test form Signups
| Status | Future |
|---|---|
| Misc Member Notes | 2 free months added for Larry Windbigler /8025524194. 2-29-16 AK xMail 2/16/17, CASH20 renew ExMail 4/4/19m ExMail 3/16/20, ExMail 4/16/2021, ExMail 05/31/22, ExMail 6/28/23, ExMail 08/07/2ExMail 08/22/2025, |
| 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. | 1755875411 |
| Your Name | Randolph Cass |
| Email hidden; Javascript is required. | |
| Phone | (419) 947-6496 |
| Date of Birth | 07/29/1947 |
| List Family Members | Pheba |
| Referred by or Referral Code | EExMail 09/29/26 |
| Enter Office Code | GM6080 |
| Administrative Code | 10DOLLARS |
| Address | 8172 Township Road 38 Galion, OH 44833 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 | 11/11/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 12/11/2027 |
| Membership ID Number | 1790698577 |
| 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. *** |
