Test form Signups
| Status | Future |
|---|---|
| Misc Member Notes | Member called in to see about mcards & never rcvd EM, updated her EM and resent, let her know cards are on the way. 04/02/20 JC Member called to upgrade to family plan. Resent SU EM, added to resend list. 9/28/2021 MT |
| 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. | 1757602355 |
| Your Name | Lois Misko |
| Email hidden; Javascript is required. | |
| Phone | (412) 913-7995 |
| Date of Birth | 07/24/1948 |
| List Family Members | Edwin (Les) |
| Referred by or Referral Code | ExMail 3/9/2020, ExMail 03/22/21, ExMail 09/11/25 |
| Enter Office Code | A14370 |
| Address | 253 Ranger Dr Pittsburgh, PA 15236 Map It |
| Payment Method | Credit Card |
| Credit Card | discover XXXXXXXXXXXX7845 |
| 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 | 10/29/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 11/29/2027 |
| Membership ID Number | 1791467624 |
| Past Plan Information | this probably isn't needed there should already be additional entries |
| Resend Sign Up Email | 10 |
| HTML Block | ***After clicking submit please wait 10 seconds for the form to process. Thank you. *** |
