Test form Signups
| Status | Future |
|---|---|
| Misc Member Notes | Member's daughter called to let us know Kathryn passed away, wanted us to take her name off. Let her know I would make the adjustment & the plan is still active until 8/2020, Dana can simply renew as an Ind next year 11/21/19 EK |
| 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. | Dc1759506727 |
| Your Name | Dana Jones |
| Email hidden; Javascript is required. | |
| Phone | (412) 427-8707 |
| Date of Birth | 03/12/1947 |
| Referred by or Referral Code | ExMail 8/4/21 |
| Address | 117 Strawberry Lane Wexford, PA 15090 Map It |
| Payment Method | Credit Card |
| Credit Card | mastercard XXXXXXXXXXXX7355 |
| 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 | 02/14/2027 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 03/14/2028 |
| Membership ID Number | 1792426577 |
| Past Plan Information | this probably isn't needed there should already be additional entries |
| Resend Sign Up Email | 8 |
| HTML Block | ***After clicking submit please wait 10 seconds for the form to process. Thank you. *** |
