Test form Signups
| Status | Future |
|---|---|
| Misc Member Notes | GFGF for referring Colleen Livingston, 1mo added, creating packet. 08/13/24 MT |
| Membership Type | Family Plan ($139.95) |
| 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. | dc1757040960 |
| Your Name | Thomas Livingston |
| Email hidden; Javascript is required. | |
| Phone | (937) 835-3211 |
| Date of Birth | 06/28/1950 |
| List Family Members | Patricia |
| Address | 887 S Diamond Mill Rd New Lebanon, OH 45345 Map It |
| Payment Method | Credit Card |
| Credit Card | visa XXXXXXXXXXXX6710 |
| 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 | 10/28/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 11/28/2027 |
| Membership ID Number | 1791030392 |
| 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. *** |
