Test form Signups

By Baljinder Singh On February 26, 2026 0 Comment

Status	Future
Misc Member Notes	Via chat found a better plan & does not wish to renew. 8/7/23 EK Called in, said he got charged the $10 etc etc. I explained and said I would refund it for being a member with us for several years. (and because prior note he was almost going to note renew). 07/25/24 JC Refunded $10 07/25/24 JC
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.	1761929774
Your Name	Johnny Wientjes
Email	Email hidden; Javascript is required.
Phone	(502) 295-9566
Date of Birth	04/03/1959
Enter Office Code	CK4549
Address	2906 westfield road louisville, KY 40220 Map It
Payment Method	Credit Card
Credit Card	visa XXXXXXXXXXXX7415
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	01/25/2027
Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here	02/25/2028
Membership ID Number	1791989559
Past Plan Information	this probably isn't needed there should already be additional entries
Resend Sign Up Email	6
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