Test form Signups
| Status | Future |
|---|---|
| Misc Member Notes | 2 free months added for Elizabeth Savona /20254798940. 11-22-16 AK Member renewed over the phone and wanted me to note that they no longer go to office DC1148, but instead go to RG4030, which is a PC2 office. 3/9/2020 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. | 1758733409 |
| Your Name | James Mahood |
| Email hidden; Javascript is required. | |
| Phone | (973) 270-7264 |
| Date of Birth | 05/09/1943 |
| Referred by or Referral Code | ExMail 09/24/2025, ExMail 10/13/26 |
| Dentist Last Name | Baragona (DC1148) |
| Administrative Code | 10DOLLARS |
| Address | PO Box 203 Pottersville, NJ 07979 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 | 11/08/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 12/08/2027 |
| Membership ID Number | 1791918822 |
| 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. *** |
