Test form Signups
| Status | Future |
|---|---|
| Misc Member Notes | Made check out to discount med plan, need to ask permission to process as an Echeck & shred physical check 4/1/19 EKReached Delores, Gave permission to process as an Echeck, wants check sent back to her 4/1/19 EK Member called in to see if he needs a bill before mailing in a check. I explained everything to him and told him we would look for the check in the mail. 5/12/2020 MT ExMail 2/7/17, ExMail 4/1/19, ExMail 5/19/2020, ExMail 5/11/21, ExMail 6/10/22, ExMail 07/11/23, ExMail 08/21/24, |
| 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. | 1758210179 |
| Your Name | Keith Armock |
| Phone | (616) 636-5261 |
| Date of Birth | 06/08/1948 |
| Referred by or Referral Code | ExMail 10/13/26 |
| Enter Office Code | DC1222 |
| Address | 8270 20 Mile Road NE Sand Lake, MI 49343 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 | 11/28/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 12/28/2027 |
| Membership ID Number | 1791918879 |
| 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. *** |
