Test form Signups
| Status | Future |
|---|---|
| Misc Member Notes | Member called to make sure she would still get 1 free month if she didn't renew Today, but later this month. 1/15/19 JCCalled today & still wanted to make sure she would get the extra month. Mailing check today & wants a call when it is received 2/11/19 KSCalled to let her know we received the check, was hung up on 2/15/19 EK ExMail 1-19-18, ExMail 2/15/19, ExMail 3/6/20, ExMail 5/4/22, ExMail 5/19/23, ExMail 08/26/2024, ExMail 08/22/2025, |
| 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. | 1755874873 |
| Your Name | Carol Ann Machalowski |
| Phone | (215) 741-8009 |
| Date of Birth | 04/29/1946 |
| Referred by or Referral Code | ExMail 10/09/2026 |
| Enter Office Code | A17083 |
| Administrative Code | 10DOLLARS |
| Address | 49-103 DeLaire Landing Rd Apt 103 Philadelphia, PA 19114 Map It |
| Payment Method | Check |
| Payment Received | Paid |
| Total | $89.95 |
| 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 | 10/28/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 11/28/2027 |
| Membership ID Number | 1791564942 |
| 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. *** |
