Test form Signups
| Status | Future |
|---|---|
| Misc Member Notes | expire letter sent 10-9-15 AKSending check in the mail to renew plan 1-17-17 CS They said sent a check in mail on 8/5/24. Told them got it. Check #640. They said hasn’t cleared bank yet. 814-823-6068, wants a call back. EM'd John P to confirm. 08/29/24 MT Member called to get mship info, added to resend list. 05/28/26 MT Mail 8-18-14, ExMail 10-19-15, Exmail 1/19/17, ExMail 1-25-18, ExMail 2/22/19, ExMail 3/26/2020, ExMail 4/29/2021, ExMail 06/07/22, ExMail 07/11/23, ExMail 08/13/24, ExMail 09/10/2025, |
| 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. | 1757520125 |
| Your Name | Thomas L Smalley Jr |
| Phone | (814) 774-3840 |
| Date of Birth | 08/18/1948 |
| Referred by or Referral Code | ExMail 10/13/26 |
| Enter Office Code | A14420 |
| Address | 800 Fairplain Rd Lake City, PA 16423 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 | 11/25/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 12/25/2027 |
| Membership ID Number | 1791918559 |
| 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. *** |
