Test form Signups
| Status | Active |
|---|---|
| Misc Member Notes | Member had issue with $10 proc fee, paid by e-check. 03/02/20 JC Paid by echeck. 10/08/26 MT |
| 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. | 1757520474 |
| Your Name | Janet Bostater |
| Phone | (419) 707-9153 |
| Date of Birth | 04/24/1937 |
| Referred by or Referral Code | ExMail 1-2-18, ExMail 1/18/19, ExMail 09/10/2025 |
| Enter Office Code | GM3422 |
| Address | 246 S State Route 590 Elmore, OH 43416 Map It |
| Payment Method | Check |
| Payment Received | Paid |
| 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 | 10/21/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 11/21/2027 |
| Membership ID Number | 1791492185 |
| 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. *** |
