Test form Signups
| Status | Future |
|---|---|
| Membership Type | Family Plan ($139.95) |
| 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. | 1757337211 |
| Your Name | Paul Trimeloni |
| Email hidden; Javascript is required. | |
| Phone | (724) 238-7435 |
| Date of Birth | 11/03/1953 |
| List Family Members | Terry |
| Referred by or Referral Code | Fax 9/2/21 |
| Enter Office Code | A13937 |
| Address | 1253 Griffith Rd Ligonier, PA 15658 Map It |
| Payment Method | Credit Card |
| Credit Card | mastercard XXXXXXXXXXXX9509 |
| Total | $139.95 |
| 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 | 02/07/2027 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 03/07/2028 |
| Membership ID Number | 1791831113 |
| Past Plan Information | this probably isn't needed there should already be additional entries |
| Resend Sign Up Email | 6 |
| HTML Block | ***After clicking submit please wait 10 seconds for the form to process. Thank you. *** |
