Test form Signups
| Status | Active |
|---|---|
| Membership Type | Family Plan ($139.95) |
| Are you renewing your plan? | No |
| Your Name | Josh Shaffer |
| Email hidden; Javascript is required. | |
| Phone | (440) 494-4159 |
| Date of Birth | 09/16/1988 |
| List Family Members | Alaina, Dominick Brown, Isaiah Doell |
| Enter Office Code | A20938 |
| Address | 6808 Madison Avenue Madison, OH 44057 Map It |
| Payment Method | Credit Card |
| Credit Card | visa XXXXXXXXXXXX2339 |
| 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 | 10/07/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 11/07/2027 |
| Membership ID Number | 1791398088 |
| Past Plan Information | this probably isn't needed there should already be additional entries |
| Resend Sign Up Email | 1 |
| HTML Block | ***After clicking submit please wait 10 seconds for the form to process. Thank you. *** |
I have read the Terms and Conditions and wish to purchase the Discount Medical Plan.


