Test form Signups
| Status | Future |
|---|---|
| Misc Member Notes | Same household as Shane 1689703372, seeing if they want to combine plans 3/11/24 EK LVM, EM sent 3/11/24 EK Called back, wants to simply extend plan now, said the office told him he was expired so he renewed. Shannon is shane. 3/11/24 JC |
| Membership Type | Individual Plan ($99.95) |
| 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. | 1758571663 |
| Your Name | Shannon Stallworth |
| Email hidden; Javascript is required. | |
| Phone | (770) 682-5280 |
| Date of Birth | 10/27/1973 |
| Enter Office Code | AJ269 |
| Address | 2140 Vinings Ln Lawrenceville, GA 30043 Map It |
| Payment Method | Credit Card |
| Credit Card | visa XXXXXXXXXXXX2824 |
| 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 | 12/12/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 01/12/2028 |
| Membership ID Number | 1792422698 |
| Past Plan Information | this probably isn't needed there should already be additional entries |
| Resend Sign Up Email | 5 |
| HTML Block | ***After clicking submit please wait 10 seconds for the form to process. Thank you. *** |
