Test form Signups
| Status | Active |
|---|---|
| Misc Member Notes | Member called in to make sure we got their check, we did, mcards on the way. 5/26/2022 MT Member said they sent in a check but we haven't received it. Told him we would give him a call once we get it. 10/09/26 MT Got check today, called member, LVM. 10/13/26 MT ExMail 05/16/22, ExMail 6/1/23, ExMail 07/31/24, ExMail 09/10/2025, |
| 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. | 1757519989 |
| Your Name | Zachary Mazack |
| Phone | (272) 227-4075 |
| Date of Birth | 02/23/2006 |
| Referred by or Referral Code | ExMail 10/13/26 |
| Enter Office Code | A12522 |
| Address | 408 Furnace St Shenandoah, PA 17976 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 | 1791919097 |
| Past Plan Information | this probably isn't needed there should already be additional entries |
| Resend Sign Up Email | 6 |
| HTML Block | ***After clicking submit please wait 10 seconds for the form to process. Thank you. *** |
