Test form Signups
| Status | Active |
|---|---|
| Misc Member Notes | Member called in to ask about the $10 processing fee and why did she get a new membership ID#. I answered her questions and she said thanks. 2/24/2020 MT |
| 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. | 1756304109 |
| Your Name | Janifer Carlson |
| Email hidden; Javascript is required. | |
| Phone | (828) 361-4312 |
| Date of Birth | 11/28/1948 |
| Enter Office Code | A20815 |
| Address | 7471 N Rio Robel Pt Hernando, FL 34442 Map It |
| Shipping Address (Optional) | 877 Reservoir Rd Murphy, NC 28906 Map It |
| Payment Method | Credit Card |
| Credit Card | mastercard XXXXXXXXXXXX2580 |
| 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 | 10/19/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 11/19/2027 |
| Membership ID Number | 1791204792 |
| 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. *** |
