Test form Signups
| Status | Active |
|---|---|
| Misc Member Notes | Requested that we send 3 cards, 1 for each member 2/1/19 KSSaid he can't find membership cards. Resend 8/12/19 KS Member was upset about the $10 processing fee. I explained and he was still upset. Got it waived for him. 3/15/2021 MT Carol called in, said Gordon Dion passed away and renewing as Ind. Adjusted this account. She wants to mail a check 7/10/24 EK She called to grumble about $10 fee, I explained and she still didn't like it, hung up before I could offer to waive it. 08/11/25 MT Member got renewal call and called in, said she sent check on 8/11. Explained we did not get it yet but will process same day, she'll get EM etc. 8/19/25 EK Member got call/letter to renew. Added space in primary name. 08/29/25 MT Member wants a list of dentists mailed since her dentist retired. I will complete 3/30/26 EK Member wants a list of dentists mailed since her dentist retired. I will complete, used list from Eric in March and added specialists to it. 09/14/26 MT member wants list of dentist sent with these zip codes 11746, 11743, 11742 10/5/26 EK |
| 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. | 1755701522 |
| Your Name | Carol Dion |
| Email hidden; Javascript is required. | |
| Phone | (516) 993-2963 |
| Date of Birth | 01/10/1945 |
| Referred by or Referral Code | ExMail 05/24/22, ExMail 07/18/24, ExMail 08/20/2025 |
| Enter Office Code | A20846 |
| Address | 179 Lodge Ave Huntington Station, NY 11746 Map It |
| Payment Method | Credit Card |
| Credit Card | amex XXXXXXXXXXXX2005 |
| 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 | 10/05/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 11/05/2027 |
| Membership ID Number | 1791213118 |
| Past Plan Information | this probably isn't needed there should already be additional entries |
| Resend Sign Up Email | 8 |
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