Test form Signups
| Status | Active |
|---|---|
| Misc Member Notes | Paid by e-check. 2/4/2021 MT ExMail 01/18/22, ExMail 2/21/23, ExMail 07/30/25, |
| 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. | 1753888127 |
| Your Name | Robin Bonner |
| Email hidden; Javascript is required. | |
| Phone | (717) 762-6368 |
| Date of Birth | 08/26/1955 |
| List Family Members | Diane |
| Referred by or Referral Code | ExMail 10/13/26 |
| Enter Office Code | DC1101 |
| Address | 8278 Sheffield Manor Blvd Waynesboro, PA 17268 Map It |
| Payment Method | Check |
| Payment Received | Paid |
| Total | $139.95 |
| 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 | 10/14/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 11/14/2027 |
| Membership ID Number | 1791917079 |
| 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. *** |
