Test form Signups

StatusActive
Membership TypeFamily Plan ($139.95)
Are you renewing your plan?No
Your NameMARIANNE PAKALINSKY
EmailEmail hidden; Javascript is required.
Phone(570) 453-8241
Date of Birth07/09/1959
List Family MembersJerry Sr, Jerome, Katrina, Emilio Cardenas
Enter Office CodeA12522
Address250 Germanville Road
Ashland, PA 17921
Map It
Payment MethodCredit Card
Credit Cardvisa
XXXXXXXXXXXX7662
Total$139.95
Go Green | Paperless Optionnot
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 here10/03/2026
Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here11/03/2027
Membership ID Number1790985899
Past Plan Informationthis probably isn't needed there should already be additional entries
Resend Sign Up Email1
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