Test form Signups
| Status | Future |
|---|---|
| Misc Member Notes | Member was referred by CORP office RG225 who can’t actively promote DC as “they said they are part of an organization that doesn’t allow that” 05/24/22 JC, 9/30/2025 EK |
| Membership Type | Family Plan ($139.95) |
| 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. | 1759248766 |
| Your Name | Shaun Graham |
| Email hidden; Javascript is required. | |
| Phone | (470) 342-4225 |
| Date of Birth | 04/22/1980 |
| List Family Members | Kristen, Brayden, Brooklyn, Berkley |
| Address | 366 Leland Ter NE Atlanta, GA 30317 Map It |
| Payment Method | Credit Card |
| Credit Card | amex XXXXXXXXXXXX6000 |
| Total | $139.95 |
| 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 | 10/31/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 12/01/2027 |
| Membership ID Number | 1792007802 |
| Past Plan Information | this probably isn't needed there should already be additional entries |
| Resend Sign Up Email | 2 |
| HTML Block | ***After clicking submit please wait 10 seconds for the form to process. Thank you. *** |
