Test form Signups
| Status | Active |
|---|---|
| Misc Member Notes | Member called and LVM, fam names should be Jill and Olivia. Updated 8/5/25 EK |
| 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. | 1754330382 |
| Your Name | Karl Fox |
| Email hidden; Javascript is required. | |
| Phone | (702) 596-6928 |
| Date of Birth | 09/18/1944 |
| List Family Members | Jill, Olivia |
| Referred by or Referral Code | Fax 8/4/25 |
| Enter Office Code | 29384 |
| Address | 833 Temple Rock Ct Boulder City, NV 89005 Map It |
| Payment Method | Credit Card |
| Credit Card | visa XXXXXXXXXXXX6832 |
| 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 | 10/05/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 11/05/2027 |
| Membership ID Number | 1791228508 |
| Past Plan Information | this probably isn't needed there should already be additional entries |
| Resend Sign Up Email | 3 |
| HTML Block | ***After clicking submit please wait 10 seconds for the form to process. Thank you. *** |
