Test form Signups
| Status | Active |
|---|---|
| Membership Type | Family Plan ($139.95) |
| Are you renewing your plan? | No |
| Your Name | MARIANNE PAKALINSKY |
| Email hidden; Javascript is required. | |
| Phone | (570) 453-8241 |
| Date of Birth | 07/09/1959 |
| List Family Members | Jerry Sr, Jerome, Katrina, Emilio Cardenas |
| Enter Office Code | A12522 |
| Address | 250 Germanville Road Ashland, PA 17921 Map It |
| Payment Method | Credit Card |
| Credit Card | visa XXXXXXXXXXXX7662 |
| 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 | 10/03/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 11/03/2027 |
| Membership ID Number | 1790985899 |
| 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. *** |
I have read the Terms and Conditions and wish to purchase the Discount Medical Plan.


