Test form Signups
| Status | Future |
|---|---|
| Misc Member Notes | How did they hear about us? EM sent, LVM 1/12/26 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. | 1768247828 |
| Your Name | Carlton Huitt |
| Email hidden; Javascript is required. | |
| Phone | (480) 688-4144 |
| Date of Birth | 08/02/1961 |
| Address | 9494 E Redfield Rd Apt. 1118 Scottsdale, AZ 85260 Map It |
| Payment Method | Credit Card |
| Credit Card | mastercard XXXXXXXXXXXX2166 |
| 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 | 02/13/2027 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 03/13/2028 |
| Membership ID Number | 1792097908 |
| 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. *** |
