Test form Signups
| Status | Active |
|---|---|
| Misc Member Notes | How does she want to pay? LVM 8/4/25 EK Got check in mail today, added to resend list. 08/07/25 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. | 1754140274 |
| Your Name | Elizabeth Vallance |
| Email hidden; Javascript is required. | |
| Phone | (812) 340-0028 |
| Date of Birth | 07/16/1946 |
| List Family Members | William E Carpenter |
| Referred by or Referral Code | ExMail 05/04/22, ExMail 6/6/23,MailedReminder2025, ExMail 08/07/2025 |
| Enter Office Code | 19144 |
| Address | 1300 E. Southdowns Dr. Bloomington, IN 47401-5149 Map It |
| Payment Method | Credit Card |
| Credit Card | mastercard XXXXXXXXXXXX7775 |
| 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 | 10/22/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 11/22/2027 |
| Membership ID Number | 1792248243 |
| Past Plan Information | this probably isn't needed there should already be additional entries |
| Resend Sign Up Email | 6 |
| HTML Block | ***After clicking submit please wait 10 seconds for the form to process. Thank you. *** |
