Test form Signups
| Status | Future |
|---|---|
| Misc Member Notes | She wanted me to add initial ‘A’ before Michele, she said for insurance purposes. 10/15/26 MT |
| 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. | 1757602294 |
| Your Name | A Michele Hewitt |
| Email hidden; Javascript is required. | |
| Phone | (330) 714-1202 |
| Date of Birth | 10/28/1946 |
| List Family Members | James |
| Referred by or Referral Code | ExMail 09/11/25 |
| Enter Office Code | RG5521 |
| Address | 11517 Giulia Dr Fort Myers, FL 33913 Map It |
| Payment Method | Credit Card |
| Credit Card | visa XXXXXXXXXXXX3468 |
| 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 | 11/25/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 12/25/2027 |
| Membership ID Number | 1792085529 |
| Past Plan Information | this probably isn't needed there should already be additional entries |
| Resend Sign Up Email | 5 |
| HTML Block | ***After clicking submit please wait 10 seconds for the form to process. Thank you. *** |
