Test form Signups
| Status | Future |
|---|---|
| Misc Member Notes | Fax 11-4-15, ExMail 1-16-18, ExMail 05/24/22, ExMail 08/22/2025, |
| 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. | 1755875361 |
| Your Name | Gary Stephens |
| Phone | (502) 477-8746 |
| Date of Birth | 07/27/1953 |
| List Family Members | Peggy |
| Referred by or Referral Code | ExMail 10/13/26 |
| Enter Office Code | CK4664 |
| Address | 8780 Mt Washington Rd Taylorsville, KY 40071 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 | 11/11/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 12/11/2027 |
| Membership ID Number | 1791917005 |
| 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. *** |
