Test form Signups
| Status | Active |
|---|---|
| Misc Member Notes | Paid with CC in Stripe bc CC field is down on SU form. 10/20/26 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. | 1743695988 |
| Your Name | Ashli Ward |
| Email hidden; Javascript is required. | |
| Phone | (303) 956-5734 |
| Date of Birth | 09/11/1990 |
| Referred by or Referral Code | ExFax 4/3/25, ExFax 10/20/26 |
| Enter Office Code | JK1574 |
| Address | 18659 Horse Creek St Parker, CO 80134 Map It |
| Payment Method | Check |
| Payment Received | Paid |
| Total | $99.95 |
| Go Green | Paperless Option | yes |
| 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 | 10/20/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 11/20/2027 |
| Membership ID Number | 1792522524 |
| Past Plan Information | this probably isn't needed there should already be additional entries |
| Resend Sign Up Email | 4 |
| HTML Block | ***After clicking submit please wait 10 seconds for the form to process. Thank you. *** |
