Test form Signups
| Status | Active |
|---|---|
| Misc Member Notes | updated tel # to match renewal. 07/11/23 JC $50 upgrade to include Tina Hill. Added to mcard resend list 4/23/25 EK Eric called and let her know we got check. 09/24/25 MT Member called to say going to send a check in the mail. 09/28/26 MT |
| Membership Type | Individual Plan ($99.95) |
| 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. | 1758732818 |
| Your Name | Barbara Russell |
| Phone | (606) 308-2365 |
| Date of Birth | 05/27/1942 |
| Referred by or Referral Code | ExMail 10/13/26 |
| Address | 530 snowflake lane mt vernon, KY 40456 Map It |
| Payment Method | Check |
| Payment Received | Paid |
| Total | $99.95 |
| 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 | 10/25/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 11/25/2027 |
| Membership ID Number | 1791918025 |
| 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. *** |
