Test form Signups
| Status | Future |
|---|---|
| Misc Member Notes | Is a renewal, same DOB on another plan, same state, (717) 762-1641 09/27/24 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. | 1757431588 |
| Your Name | James Rickett |
| Email hidden; Javascript is required. | |
| Phone | (301) 302-2535 |
| Date of Birth | 05/11/1941 |
| Referred by or Referral Code | Phyllis Helm -member, done, ExMail 8-16-17, ExMail 9-27-18, ExMail 10/31/19, ExMail 12/16/2020, ExMail 1/3/22 |
| Address | 11072 Ridge Crest Drive Waynesboro, PA 17268 Map It |
| Payment Method | Credit Card |
| Credit Card | mastercard XXXXXXXXXXXX0664 |
| Total | $99.95 |
| Go Green | Paperless Option | yes |
| 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 | 11/28/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 12/28/2027 |
| Membership ID Number | 1791294356 |
| 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. *** |
