Test form Signups
| Status | Future |
|---|---|
| Misc Member Notes | Mail 4/15/19 ExMail 3/31/2020, ExMail 05/13/21, ExMail 07/11/23, ExMail 08/21/24, ExMail 10/20/25, ExMail 10/13/26 |
| 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. | 1760966633 |
| Your Name | Randy Carroll |
| Email hidden; Javascript is required. | |
| Phone | (740) 286-6121 |
| Date of Birth | 10/02/1949 |
| List Family Members | Doris |
| Referred by or Referral Code | Mary Faith Spires 41140567311 member, done., |
| Address | 563 Cutlip Rd Jackson, OH 45640 Map It |
| Payment Method | Check |
| Payment Received | Paid |
| 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 | 11/22/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 12/22/2027 |
| Membership ID Number | 1791916784 |
| 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. *** |
