Test form Signups
| Status | Active |
|---|---|
| Misc Member Notes | GiveFreeGetFree 1 free month added for referred by Karen Miller 1584727202. EM sent. 04/07/21 JC Member needed mcards, added to resend list. 01/09/2023 MT |
| 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. | 1758541451 |
| Your Name | Susan Winningham |
| Email hidden; Javascript is required. | |
| Phone | (586) 994-9911 |
| Date of Birth | 07/24/1957 |
| Referred by or Referral Code | Karen Miller 1584727202 member, done. |
| Address | 18049 Redwood Dr Macomb, MI 48042 Map It |
| Payment Method | Credit Card |
| Credit Card | mastercard XXXXXXXXXXXX4426 |
| 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 | 10/23/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 11/23/2027 |
| Membership ID Number | 1792425427 |
| 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. *** |
