Test form Signups
| Status | Future |
|---|---|
| Misc Member Notes | Offered to waive processing fee, sending in a check 2-18-149 EK Member called because he was not able to find his card, but he did end up finding it. He verified the plan info and said he's all set. 2/10/2020 MT ExMail 10-30-15, ExMail 1-13-17, ExMail 1-23-18, ExMail 2/21/19, ExMail 3/31/2020, ExMail 05/05/21, ExMail 6/16/22, ExMail 7/13/23, ExMail 08/02/24, ExMail 09/24/2025, |
| Membership Type | Family Plan ($139.95) |
| 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. | 1758733767 |
| Your Name | Roger Butler |
| Phone | (419) 885-1356 |
| Date of Birth | 01/26/1942 |
| List Family Members | Dorothy |
| Referred by or Referral Code | ExMail 10/20/26 |
| Enter Office Code | DC372 |
| Address | 7840 Saltwood Court Sylvania, OH 43560 Map It |
| Payment Method | Check |
| Payment Received | Paid |
| Total | $139.95 |
| 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 | 11/21/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 12/21/2027 |
| Membership ID Number | 1792524747 |
| 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. *** |
