Test form Signups
| Status | Active |
|---|---|
| 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. | 1757258599 |
| Your Name | Lloyd Johnson |
| Email hidden; Javascript is required. | |
| Phone | (480) 595-1802 |
| Date of Birth | 12/29/1946 |
| List Family Members | Barbara |
| Referred by or Referral Code | ExMail 07/05/24 |
| Enter Office Code | DC1215 |
| Address | 40417 N 64th Place Cave Creek, AZ 85331 Map It |
| Shipping Address (Optional) | PO Box 4066 Cave Creek, AZ 85327 Map It |
| Payment Method | Credit Card |
| Credit Card | visa XXXXXXXXXXXX5856 |
| 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 | 10/10/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 11/10/2027 |
| Membership ID Number | 1791411126 |
| Past Plan Information | this probably isn't needed there should already be additional entries |
| Resend Sign Up Email | 6 |
| HTML Block | ***After clicking submit please wait 10 seconds for the form to process. Thank you. *** |
