Test form Signups
| Status | Future |
|---|---|
| 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. | 1755033767 |
| Your Name | Dennis Perliski |
| Email hidden; Javascript is required. | |
| Phone | (586) 382-2324 |
| Date of Birth | 03/22/1956 |
| List Family Members | Antoinette |
| Enter Office Code | A22283 |
| Address | 49684 Broadacre Dr Macomb, MI 48042 Map It |
| Payment Method | Credit Card |
| Credit Card | visa XXXXXXXXXXXX8541 |
| 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 | 01/12/2027 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 02/12/2028 |
| Membership ID Number | 1790884381 |
| Past Plan Information | this probably isn't needed there should already be additional entries |
| Resend Sign Up Email | 4 |
| HTML Block | ***After clicking submit please wait 10 seconds for the form to process. Thank you. *** |
