Test form Signups
| Status | Active |
|---|---|
| Misc Member Notes | GFGF Recipient 10/14/26 EK |
| Membership Type | Individual Plan ($99.95) |
| Are you renewing your plan? | No |
| Your Name | Barbara Furman |
| Phone | (607) 962-7889 |
| Date of Birth | 07/09/1943 |
| Referred by or Referral Code | Kimberly Weaver 1791815640 Done |
| Enter Office Code | DC1295 |
| Address | 2534 Fairway Rd Corning, NY 14830 Map It |
| Payment Method | Credit Card |
| Credit Card | mastercard XXXXXXXXXXXX4446 |
| 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 | 10/14/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 12/14/2027 |
| Membership ID Number | 1791988976 |
| Past Plan Information | this probably isn't needed there should already be additional entries |
| Resend Sign Up Email | 1 |
| HTML Block | ***After clicking submit please wait 10 seconds for the form to process. Thank you. *** |
