Test form Signups
| Status | Future |
|---|---|
| Misc Member Notes | Office call in 8/15/23, ExMail 08/07/2024, ExMail 09/29/25, |
| 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. | 1759173077 |
| Your Name | Rebecca Jordan |
| Phone | (570) 874-1719 |
| Date of Birth | 03/17/1950 |
| Referred by or Referral Code | ExMail 10/13/26 |
| Enter Office Code | A12522 |
| Administrative Code | 10DOLLARS |
| Address | 27 Spruce St Ashland, PA 17921 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 | 11/18/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 12/18/2027 |
| Membership ID Number | 1791918634 |
| Past Plan Information | this probably isn't needed there should already be additional entries |
| Resend Sign Up Email | 4 |
| HTML Block | ***After clicking submit please wait 10 seconds for the form to process. Thank you. *** |
