Test form Signups
| Status | Future |
|---|---|
| Misc Member Notes | ExMail 2/28/19, ExMail 3/31/2020, ExMail 05/05/21, ExMail 06/06/22, ExMail 6/28/23, ExMail 7/29/24, ExMail 09/11/25, |
| 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. | 1757602488 |
| Your Name | Bonnie Roper |
| Email hidden; Javascript is required. | |
| Phone | (614) 315-2468 |
| Date of Birth | 10/04/1946 |
| List Family Members | William |
| Referred by or Referral Code | ExMail 10/13/26 |
| Enter Office Code | GM3422 |
| Address | 1859 NE Catawba Rd #109 Port Clinton, OH 43452 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 | 11/15/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 12/15/2027 |
| Membership ID Number | 1791917138 |
| 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. *** |
