Test form Signups
| Status | Active |
|---|---|
| Membership Type | Individual Plan ($99.95) |
| Are you renewing your plan? | No |
| Your Name | Victor Fernandez |
| Email hidden; Javascript is required. | |
| Phone | (570) 285-2314 |
| Date of Birth | 10/17/1994 |
| Referred by or Referral Code | Fax 10/16/26 |
| Enter Office Code | A13366 |
| Address | 30 E Ridge St, #30 Nanticoke, PA 18634 Map It |
| Payment Method | Credit Card |
| Credit Card | visa XXXXXXXXXXXX8362 |
| 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 | 10/16/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 11/16/2027 |
| Membership ID Number | 1792155743 |
| 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. *** |
