Test form Signups
| Status | Future |
|---|---|
| Membership Type | Individual Plan ($99.95) |
| 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. | 1758734102 |
| Your Name | Susan Stolitza |
| Email hidden; Javascript is required. | |
| Phone | (216) 741-3416 |
| Date of Birth | 12/18/1947 |
| Referred by or Referral Code | ExMail 09/24/2025, ExMail 10/01/2026 |
| Enter Office Code | GM4975 |
| Address | 4167 W. 48th Street Cleveland, OH 44144 Map It |
| Payment Method | Check |
| Payment Received | Paid |
| Total | $99.95 |
| Go Green | Paperless Option | yes |
| 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 | 11/06/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 12/06/2027 |
| Membership ID Number | 1790869688 |
| Past Plan Information | this probably isn't needed there should already be additional entries |
| Resend Sign Up Email | 3 |
| HTML Block | ***After clicking submit please wait 10 seconds for the form to process. Thank you. *** |
