Test form Signups
| Status | Future |
|---|---|
| Misc Member Notes | paid by E-check 6/23/22 EK Fax 6/23/22, ExMail 6/12/23, ExMail 07/18/24, 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. | 1755874928 |
| Your Name | Carol Gulibon |
| Phone | (724) 593-2067 |
| Date of Birth | 12/26/1945 |
| Referred by or Referral Code | ExMail 10/13/26 |
| Enter Office Code | A13937 |
| Address | 327 Old Distillery Stahlstown, PA 15687 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 | 10/27/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 11/27/2027 |
| Membership ID Number | 1791919034 |
| Past Plan Information | this probably isn't needed there should already be additional entries |
| Resend Sign Up Email | 5 |
| HTML Block | ***After clicking submit please wait 10 seconds for the form to process. Thank you. *** |
