Test form Signups
| Status | Future |
|---|---|
| Misc Member Notes | Member called in to make sure they had renewed saying they keep rcv'ing exp notices. told her I do not see a future plan for her. She said she's positive she renewed she will check with her bank. Said she'll call us back to renew later. 12/09/20 JC |
| 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. | 1756920386 |
| Your Name | L. Michelle Harris |
| Email hidden; Javascript is required. | |
| Phone | (412) 709-2447 |
| Date of Birth | 12/02/1948 |
| List Family Members | Raymond |
| Address | 98 Williamson Rd Greenville, PA 16125 Map It |
| Payment Method | Check |
| Payment Received | Paid |
| 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 | 11/24/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 12/24/2027 |
| Membership ID Number | 1791222208 |
| 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. *** |
