Test form Signups
| Status | Active |
|---|---|
| Membership Type | Individual Plan ($99.95) |
| Are you renewing your plan? | No |
| Your Name | Brandon Scott |
| Email hidden; Javascript is required. | |
| Phone | (480) 225-3705 |
| Date of Birth | 04/08/1984 |
| Enter Office Code | DC1215 |
| Address | 6016 East Monte Cristo Scottsdale, AZ 85254 Map It |
| Payment Method | Credit Card |
| Credit Card | visa XXXXXXXXXXXX2182 |
| 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 | 10/09/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 11/09/2027 |
| Membership ID Number | 1791580565 |
| Past Plan Information | this probably isn't needed there should already be additional entries |
| Resend Sign Up Email | 1 |
| HTML Block | ***After clicking submit please wait 10 seconds for the form to process. Thank you. *** |
I have read the Terms and Conditions and wish to purchase the Discount Medical Plan.


