Test form Signups
| Status | Future |
|---|---|
| Misc Member Notes | How did they hear about us? 09/03/24 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. | 1752528217 |
| Your Name | THOMAS LOWE |
| Email hidden; Javascript is required. | |
| Phone | (570) 527-7747 |
| Date of Birth | 02/23/1955 |
| List Family Members | Mary Ellen |
| Enter Office Code | A12522 |
| Address | 146 N 4th St Frackville, PA 17931 Map It |
| Payment Method | Credit Card |
| Credit Card | discover XXXXXXXXXXXX7583 |
| 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 | 11/03/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 12/03/2027 |
| Membership ID Number | 1792176608 |
| Past Plan Information | this probably isn't needed there should already be additional entries |
| Resend Sign Up Email | 3 |
| HTML Block | ***After clicking submit please wait 10 seconds for the form to process. Thank you. *** |
