Test form Signups
| Status | Active |
|---|---|
| Misc Member Notes | Check for renewal made out to carington & cannot process, need to get permission to process as an E-check, ask if we can shred it, LVM 2-4-19 EKsaid we can shred check & process as an E-check 2/7/19 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. | 1758136511 |
| Your Name | Giuliano Monini |
| Email hidden; Javascript is required. | |
| Phone | (215) 725-1246 |
| Date of Birth | 01/09/1955 |
| Referred by or Referral Code | ExMail 1-8-18, ExMail 2/4/19, ExMail 2/24/2020, ExMail 5/11/21 |
| Enter Office Code | A17083 |
| Address | 7527 Dorcas St Philadelphia, PA 19111 Map It |
| Payment Method | Credit Card |
| Credit Card | mastercard XXXXXXXXXXXX0817 |
| 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 | 10/21/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 11/21/2027 |
| Membership ID Number | 1791910761 |
| Past Plan Information | this probably isn't needed there should already be additional entries |
| Resend Sign Up Email | 8 |
| HTML Block | ***After clicking submit please wait 10 seconds for the form to process. Thank you. *** |
