Test form Signups
| Status | Future |
|---|---|
| Misc Member Notes | kesheehan is the EM written without domain… refaxing app with payment info since blank first time. 12-14-16 AK Fax 12-14-16, ExMail 07/12/22, ExMail 07/17/23, ExMail 09/11/24, ExMail 09/11/25, |
| 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. | 1757602159 |
| Your Name | Kathy Sheehan |
| Phone | (719) 546-0127 |
| Date of Birth | 01/30/1947 |
| Referred by or Referral Code | ExMail 10/13/26 |
| Enter Office Code | JK1775 |
| Administrative Code | 10DOLLARS |
| Address | 304 Argyle Ave Pueblo, CO 81004 Map It |
| Payment Method | Check |
| Payment Received | Paid |
| Total | $89.95 |
| 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 | 11/21/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 12/21/2027 |
| Membership ID Number | 1791918112 |
| 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. *** |
