Test form Signups
| Status | Future |
|---|---|
| Misc Member Notes | Mike Carsey – Nonmember. |
| 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. | DC1765504539 |
| Your Name | Michael Catherwood |
| Email hidden; Javascript is required. | |
| Phone | (402) 983-2908 |
| Date of Birth | 11/16/1956 |
| Referred by or Referral Code | Mike Carsey Nonmember Done |
| Address | 625 Pine Rd Omaha, NE 68144 Map It |
| Payment Method | PayPal |
| 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 | 12/31/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 01/31/2028 |
| Membership ID Number | 1792004254 |
| 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. *** |
| Payment Method | PayPal Checkout |
