Test form Signups
| Status | Future |
|---|---|
| Misc Member Notes | Renewed as IND with fam members listed, calling to see if they want to upgrade to FAM. spoke with Carol and got payment info for $40 upgrade. 01/03/20 JC |
| 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. | 1757090342 |
| Your Name | CAROL NORWOOD |
| Email hidden; Javascript is required. | |
| Phone | (352) 322-1598 |
| Date of Birth | 03/28/1950 |
| List Family Members | Harry |
| Enter Office Code | A20815 |
| Address | 5429 SW 191st Ct Dunnellon, FL 34432 Map It |
| Payment Method | Credit Card |
| Credit Card | mastercard XXXXXXXXXXXX3913 |
| 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 | 11/09/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 12/09/2027 |
| Membership ID Number | 1791560039 |
| Past Plan Information | this probably isn't needed there should already be additional entries |
| Resend Sign Up Email | 9 |
| HTML Block | ***After clicking submit please wait 10 seconds for the form to process. Thank you. *** |
