Test form Signups
| Status | Future |
|---|---|
| Misc Member Notes | LVM, need to get FAM members for Rnwl. 2/25/19 JCSent EM to get FAM members. 2/27/19 JCCalled & gave family members she wanted listed on the plan 3/1/19 KS Member sent CASH20 by mistake. Fixed the dates. EM is unsubbed in MC. 10/14/26 EK |
| 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. | DC1738613225 |
| Your Name | Richard Lanser |
| Email hidden; Javascript is required. | |
| Phone | (262) 853-3020 |
| Date of Birth | 07/18/1958 |
| Referred by or Referral Code | ExFax 2/3/25 |
| Enter Office Code | JKZ536 |
| Administrative Code | CASH20 |
| Address | 1755 Horns Corners Road Cedarburg, WI 53012 Map It |
| Payment Method | Credit Card |
| Credit Card | mastercard XXXXXXXXXXXX9666 |
| Total | $79.95 |
| 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 | 04/05/2027 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 05/05/2028 |
| Membership ID Number | 1791989957 |
| Past Plan Information | this probably isn't needed there should already be additional entries |
| Resend Sign Up Email | 4 |
| HTML Block | ***After clicking submit please wait 10 seconds for the form to process. Thank you. *** |
