Test form Signups
| Status | Active |
|---|---|
| Misc Member Notes | GFGF for Barbara Furman DC1791988976 10/14/26 EK |
| Membership Type | Family Plan ($139.95) |
| Are you renewing your plan? | No |
| Your Name | Ronald Weaver |
| Email hidden; Javascript is required. | |
| Phone | (607) 731-8967 |
| Date of Birth | 12/30/1960 |
| List Family Members | Kimberly |
| Dentist Last Name | Uy (DC1295) |
| Address | 429 Laurentian Place ELMIRA, NY 14904 Map It |
| Payment Method | Credit Card |
| Credit Card | visa XXXXXXXXXXXX3041 |
| 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 | 10/12/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 12/12/2027 |
| Membership ID Number | 1791815640 |
| 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. *** |
