Test form Signups
| Status | Active |
|---|---|
| Misc Member Notes | Member did not get mcards, paperless was checked, resent SU EM, added to resend list. 09/27/2022 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. | 1754760948 |
| Your Name | Mike Auer |
| Email hidden; Javascript is required. | |
| Phone | (925) 548-6946 |
| Date of Birth | 03/30/1958 |
| List Family Members | Jacki |
| Enter Office Code | 6903 |
| Address | 7716 mount evans way ROSEVILLE, CA 95747 Map It |
| Payment Method | Credit Card |
| Credit Card | visa XXXXXXXXXXXX4393 |
| 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 | 1790793096 |
| Past Plan Information | this probably isn't needed there should already be additional entries |
| Resend Sign Up Email | 7 |
| HTML Block | ***After clicking submit please wait 10 seconds for the form to process. Thank you. *** |
