Test form Signups
| Status | Active |
|---|---|
| Misc Member Notes | Ceil called and just wanted to verify that his plan was active 1/3/2020 KS Ceil thought she was ready to get work done when she signed up. She is dealing with a medical issue and was advised by her Dr. not to get any dental work done for 2-3 months, and has not had a chance to use the plan. She does not want to lose time on her plan while she is waiting, seeking a refund for now. She wishes to sign back up in 2-3 months to take advantage of the full membership time. Refund Pending $89.95. 1/14/20 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. | 1757512747 |
| Your Name | Ceil Safdieh |
| Phone | (732) 531-4043 |
| Date of Birth | 07/04/1936 |
| Enter Office Code | RG3433 |
| Address | 404 Sherman Ave Deal, NJ 07723 Map It |
| Payment Method | Credit Card |
| Credit Card | visa XXXXXXXXXXXX1558 |
| Total | $99.95 |
| 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 | 10/11/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 11/11/2027 |
| Membership ID Number | 1791463353 |
| Past Plan Information | this probably isn't needed there should already be additional entries |
| Resend Sign Up Email | 7 |
| HTML Block | ***After clicking submit please wait 10 seconds for the form to process. Thank you. *** |
