Test form Signups
| Status | Active |
|---|---|
| Misc Member Notes | Adjusted dates, resent SU EM. 08/06/25 MT GFGF, 1mo added for referring Tami Tripp. 07/29/26 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. | DC1754483890 |
| Your Name | Jeffrey Massie |
| Email hidden; Javascript is required. | |
| Phone | (775) 537-7577 |
| Date of Birth | 02/13/1955 |
| Referred by or Referral Code | Fax 8/5/25 |
| Enter Office Code | 29384 |
| Address | 4270 Placer Lane Pahrump, NV 89060 Map It |
| Payment Method | Credit Card |
| Credit Card | visa XXXXXXXXXXXX3032 |
| 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 | 10/06/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 11/06/2027 |
| Membership ID Number | 1791296328 |
| 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. *** |
