Test form Signups
| Status | Future |
|---|---|
| Misc Member Notes | Adjusted dates, re-sent SU EM. 12/30/19 JC |
| 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. | DC1756661476 |
| Your Name | Marjorie Sellers |
| Email hidden; Javascript is required. | |
| Phone | (412) 855-1810 |
| Date of Birth | 07/08/1948 |
| Enter Office Code | PA318 |
| Address | 406 ROOSEVELT AVE PITTSBURGH, PA 15202 Map It |
| Payment Method | Credit Card |
| Credit Card | visa XXXXXXXXXXXX8520 |
| 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 | 11/05/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 12/05/2027 |
| Membership ID Number | 1791735972 |
| 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. *** |
