Test form Signups
| Status | Active |
|---|---|
| Misc Member Notes | Adjusted dates/resent EM. 12/02/20 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. | 1752234413 |
| Your Name | Robert Kizis |
| Email hidden; Javascript is required. | |
| Phone | (570) 237-1878 |
| Date of Birth | 10/29/1973 |
| Enter Office Code | A13366 |
| Address | 108 Searle st Pittston, PA 18640 Map It |
| Payment Method | PayPal |
| Total | $99.95 |
| Go Green | Paperless Option | yes |
| 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 | 10/12/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 11/12/2027 |
| Membership ID Number | 1791812521 |
| Past Plan Information | this probably isn't needed there should already be additional entries |
| Resend Sign Up Email | 7 |
| HTML Block | ***After clicking submit please wait 10 seconds for the form to process. Thank you. *** |
| Payment Method | PayPal Checkout |
