Test form Signups
| Status | Future |
|---|---|
| Misc Member Notes | GFGF for David Dykstra DC1710863078 3/19/24 EK |
| 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. | 1758540253 |
| Your Name | Richard Dykstra |
| Email hidden; Javascript is required. | |
| Phone | (607) 376-1077 |
| Date of Birth | 12/14/1955 |
| List Family Members | Carol Ann |
| Enter Office Code | 29775 |
| Address | 54063 State Highway 30 P.O. Box 267 Roxbury, NY 12474 Map It |
| Payment Method | Credit Card |
| Credit Card | visa XXXXXXXXXXXX3673 |
| 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 | 02/05/2027 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 03/05/2028 |
| Membership ID Number | 1791911961 |
| Past Plan Information | this probably isn't needed there should already be additional entries |
| Resend Sign Up Email | 4 |
| HTML Block | ***After clicking submit please wait 10 seconds for the form to process. Thank you. *** |
