Test form Signups
| Status | Future |
|---|---|
| Misc Member Notes | GFGF for Patricia Knaggs DC1729704103 10/23/24 EK |
| 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. | 1757188636 |
| Your Name | Elizabeth Bartlett |
| Email hidden; Javascript is required. | |
| Phone | (586) 907-8517 |
| Date of Birth | 09/22/1950 |
| Enter Office Code | A22283 |
| Address | 56728 HASTINGS DR MACOMB, MI 48042 Map It |
| Payment Method | Credit Card |
| Credit Card | mastercard XXXXXXXXXXXX4030 |
| 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 | 11/21/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 12/21/2027 |
| Membership ID Number | 1791460693 |
| Past Plan Information | this probably isn't needed there should already be additional entries |
| Resend Sign Up Email | 8 |
| HTML Block | ***After clicking submit please wait 10 seconds for the form to process. Thank you. *** |
