Test form Signups
| Status | Future |
|---|---|
| Misc Member Notes | GFGF recipient, 1mo added. He called in bc he forgot to put office code in. 10/02/24 MT Member called to update address and have mcards resent. 01/30/26 MT Member called to upgrade to fam plan, $50 in Stripe, resent EM, added to resend list. 05/01/26 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. | 1766865162 |
| Your Name | Ronald Raffa |
| Email hidden; Javascript is required. | |
| Phone | (716) 397-8804 |
| Date of Birth | 10/11/1959 |
| List Family Members | Amy |
| Referred by or Referral Code | Joyce Atkinson 1727370586-member done |
| Enter Office Code | A20831 |
| Address | 150 Patterson Dr Stewartstown, PA 17363 Map It |
| Payment Method | Credit Card |
| Credit Card | visa XXXXXXXXXXXX5587 |
| 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 | 01/28/2027 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 02/28/2028 |
| Membership ID Number | 1792091606 |
| 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. *** |
