Test form Signups
| Status | Future |
|---|---|
| Misc Member Notes | 1 free month added for Kenneth Seidl 41341204958. 5/6/19 JC1 free month removed for Kenneth Seidl 41341204958 cancellation. 5/30/19 BH Member called in bc he said his card wasn't billed and he didn't receive an EM saying that he renewed, I let him know he did and resent SU EM. 1/3/20 MT GIVEFREEGETFREE Flyer for referring Debbie Petrilli DC1581632969. 2/14/2020 BH Member LVM over the weekend, Called and LVM. IND or FAM? 01/04/21 JC 2 months added for referring Toby Kaplan-1609735461, Gary not on GIVEFREEGETFREE. 1/4/2021 MT Gary called in, supposed to be the family plan. Got payment for $40 upgrade, resent the SU EM. Added to Mcard resend master 1/7/21 EK Updated phone to match active plan, this had an extra '1'. 6/6/22 MT Member called to make sure renewal payment went through, said he was having trouble with the card, checked Stripe, payment appears fine. 08/30/24 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. | DC1757728140 |
| Your Name | Gary Ernat |
| Email hidden; Javascript is required. | |
| Phone | (586) 242-9050 |
| Date of Birth | 08/24/1943 |
| List Family Members | Karen |
| Enter Office Code | A22511 |
| Address | 36388 Summerset St Sterling Heights, MI 48312 Map It |
| Payment Method | Credit Card |
| Credit Card | visa XXXXXXXXXXXX5191 |
| 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 | 11/07/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 12/07/2027 |
| Membership ID Number | 1792204298 |
| Past Plan Information | this probably isn't needed there should already be additional entries |
| Resend Sign Up Email | 11 |
| HTML Block | ***After clicking submit please wait 10 seconds for the form to process. Thank you. *** |
