Test form Signups
| Status | Future |
|---|---|
| Misc Member Notes | MARY ANN WILLIS active until 3/6/18, RNWL dwn grd 2-5-18 SS alt # 717-436-9583Member upgraded to fam plan adding mary ann back on plan. 3-14-18 s.p Member Mary Ann has insurance for herself now, wants to downgrade to individual plan for just Anthony and requested a refund for the difference. Partial Refund Pending $40. 6/22/2021 MT Member called to add Mary Ann, $50 Upgrade in Stripe, added to mcard resend list 1/17/24 EK |
| 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. | 1754321855 |
| Your Name | ANTHONY WILLIS |
| Email hidden; Javascript is required. | |
| Phone | (717) 363-0035 |
| Date of Birth | 11/21/1956 |
| Address | 1 BREEZY LN MIFFLINTOWN, PA 17059 Map It |
| Payment Method | Credit Card |
| Credit Card | mastercard XXXXXXXXXXXX3309 |
| 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 | 11/13/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 12/13/2027 |
| Membership ID Number | 1791820776 |
| 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. *** |
