Test form Signups
| Status | Active |
|---|---|
| Misc Member Notes | EXPIRED letter returned 8/1/24, LVM EK Mcards returned, marked 'not deliverable as addressed'. Called, LVM, EM temp sent.//Member called back, said address is correct. Added to resend list. 10/06/25 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. | 1757352871 |
| Your Name | Vivian Pang |
| Email hidden; Javascript is required. | |
| Phone | (909) 525-7658 |
| Date of Birth | 04/24/1975 |
| List Family Members | Ruuhwa Dann |
| Referred by or Referral Code | Fax 05/11/23 |
| Enter Office Code | 29384 |
| Address | 10400 Summit Canyon Dr Las Vegas, NV 89144 Map It |
| Payment Method | Credit Card |
| Credit Card | visa XXXXXXXXXXXX4873 |
| 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 | 10/11/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 11/11/2027 |
| Membership ID Number | 1791221924 |
| Past Plan Information | this probably isn't needed there should already be additional entries |
| Resend Sign Up Email | 4 |
| HTML Block | ***After clicking submit please wait 10 seconds for the form to process. Thank you. *** |
