Test form Signups
| Status | Active |
|---|---|
| Misc Member Notes | upgraded plan. 1-10-17 AK LVM 10-23-17 SS LVM 10-24-17 SS Member was trying to see if DLN Schnoor was in network, not appearing on my list, but she said it was on hers. I told her they would have to contact DM, explained DM and how we utilize it. I gave her some GP's over the phone. 11/9/2021 MT |
| 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. | 1755872694 |
| Your Name | Linda Schlachter-Quicker |
| Email hidden; Javascript is required. | |
| Phone | (419) 349-4476 |
| Date of Birth | 11/18/1945 |
| Referred by or Referral Code | Vicki Peckham -member, done |
| Address | 3506 Deepwood Drive Lambertville, MI 48144 Map It |
| Payment Method | Credit Card |
| Credit Card | visa XXXXXXXXXXXX2103 |
| 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 | 10/16/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 11/16/2027 |
| Membership ID Number | 1790955952 |
| Past Plan Information | this probably isn't needed there should already be additional entries |
| Resend Sign Up Email | 8 |
| HTML Block | ***After clicking submit please wait 10 seconds for the form to process. Thank you. *** |
