Test form Signups
| Status | Future |
|---|---|
| Misc Member Notes | Member called to update to fam plan, $40. 10/14/25 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. | 1760384057 |
| Your Name | Katalin Kluger |
| Email hidden; Javascript is required. | |
| Phone | (719) 354-7088 |
| Date of Birth | 04/10/1975 |
| List Family Members | Peter |
| Referred by or Referral Code | Fax 10/13/25 |
| Enter Office Code | JK1775 |
| Address | 579 W Golfwood Pueblo, CO 81007 Map It |
| Payment Method | Credit Card |
| Credit Card | visa XXXXXXXXXXXX9674 |
| 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 | 11/14/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 12/14/2027 |
| Membership ID Number | 1792179101 |
| 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. *** |
