Test form Signups
| Status | Active |
|---|---|
| Membership Type | Individual Plan ($99.95) |
| Are you renewing your plan? | No |
| Your Name | Paul Francisco |
| Email hidden; Javascript is required. | |
| Phone | (831) 214-5760 |
| Date of Birth | 01/30/1965 |
| Enter Office Code | RG6131 |
| Address | 9 9 Wimbledon Circle Salinas, CA 93906 Map It |
| Payment Method | Credit Card |
| Credit Card | visa XXXXXXXXXXXX1854 |
| Total | $99.95 |
| 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 | 10/01/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 11/01/2027 |
| Membership ID Number | 1790899004 |
| 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. *** |
