Test form Signups
| Status | Active |
|---|---|
| Membership Type | Family Plan ($139.95) |
| Are you renewing your plan? | No |
| Your Name | Amanda Carter |
| Email hidden; Javascript is required. | |
| Phone | (586) 453-5502 |
| Date of Birth | 05/28/1973 |
| List Family Members | Emily, Jackson |
| Enter Office Code | A22283 |
| Address | 11151 Shadow Creek Court Sterling Heights, MI 48313 Map It |
| Payment Method | Credit Card |
| Credit Card | visa XXXXXXXXXXXX0674 |
| Total | $139.95 |
| Go Green | Paperless Option | yes |
| 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 | 1791040662 |
| 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.


