Test form Signups
| Status | Active |
|---|---|
| Misc Member Notes | How did they hear about us? EM sent, LVM 09/30/2026 EK |
| Membership Type | Family Plan ($139.95) |
| Are you renewing your plan? | No |
| Your Name | Kevin Bert |
| Email hidden; Javascript is required. | |
| Phone | (262) 674-0611 |
| Date of Birth | 07/23/1957 |
| List Family Members | Kathryn |
| Address | 2292 Ridgewood Road Grafton, WI 53024 Map It |
| Payment Method | Credit Card |
| Credit Card | visa XXXXXXXXXXXX4689 |
| Total | $139.95 |
| 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 | 1790730773 |
| Past Plan Information | this probably isn't needed there should already be additional entries |
| Resend Sign Up Email | 1 |
| HTML Block | ***After clicking submit please wait 10 seconds for the form to process. Thank you. *** |
I have read the Terms and Conditions and wish to purchase the Discount Medical Plan.


