Test form Signups
| Status | Active |
|---|---|
| Misc Member Notes | Paid by e-check. 02/24/20 JC |
| 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. | 1754071127 |
| Your Name | Patricia Farnsworth-Ickes |
| Phone | (412) 885-3877 |
| Date of Birth | 06/02/1951 |
| Referred by or Referral Code | ExMail 1/16/19, ExMail 3/31/2021, ExMail 07/05/24 |
| Enter Office Code | A13764 |
| Address | 3253 Shadyway Dr Pittsburgh, PA 15227 Map It |
| Payment Method | Credit Card |
| Credit Card | visa XXXXXXXXXXXX4887 |
| 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 | 10/21/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 11/21/2027 |
| Membership ID Number | 1790957105 |
| 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. *** |
