Test form Signups

StatusActive
Misc Member Notes

How did they hear about us? EM sent, LVM 09/30/2026 EK

Membership TypeFamily Plan ($139.95)
Are you renewing your plan?No
Your NameKevin Bert
EmailEmail hidden; Javascript is required.
Phone(262) 674-0611
Date of Birth07/23/1957
List Family MembersKathryn
Address2292 Ridgewood Road
Grafton, WI 53024
Map It
Payment MethodCredit Card
Credit Cardvisa
XXXXXXXXXXXX4689
Total$139.95
Go Green | Paperless Optionnot
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 here09/30/2026
Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here10/30/2027
Membership ID Number1790730773
Past Plan Informationthis probably isn't needed there should already be additional entries
Resend Sign Up Email1
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