Test form Signups
| Status | Active |
|---|---|
| Misc Member Notes | 1 free month added for Barbara Ely /40070805374. 4-20-17 AK Member received CASH20 letter by mistake due to change in address, I explained but he said he would like to renew early to take advantage of the $20 discount. 9/30/2020 EK Mary called to get the plan in her name, husband deceased. Will renew closer to Exp when she gets Exp letter 1/6/22 EK Member called in to make sure we got her check, said she keeps getting notices. 10/19/26 MT ExMail 2/7/2020, CASH20 Renew 9/30/2020, ExMail 8/6/24, ExMail 08/22/2025, |
| 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. | 1755875125 |
| Your Name | Mary Lucas |
| Email hidden; Javascript is required. | |
| Phone | (412) 881-3876 |
| Date of Birth | 08/23/1953 |
| Referred by or Referral Code | ExMail 10/13/26 |
| Enter Office Code | A14370 |
| Address | 31 Clifton Blvd Pittsburgh, PA 15210 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 | 10/13/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 11/13/2027 |
| Membership ID Number | 1791918701 |
| 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. *** |
