Test form Signups
| Status | Active |
|---|---|
| Misc Member Notes | Member's wife called for email receipt of their old plan from 2023. Sent to [email protected] in Stripe. Discussed upgrade options also. 5/12/25 EK Called to upgrade to fam plan, $40 in Stripe. 09/17/25 MT Called back to change back to ind plan, refunded $40 in Stripe, removed Barbara. 09/17/25 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. | 1758136829 |
| Your Name | George Dragon |
| Email hidden; Javascript is required. | |
| Phone | (719) 489-2199 |
| Date of Birth | 09/09/1945 |
| Enter Office Code | JK1775 |
| Address | 8230 PARK RD Rye, CO 81069 Map It |
| Payment Method | Credit Card |
| Credit Card | visa XXXXXXXXXXXX9903 |
| 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 | 1792437031 |
| 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. *** |
