Test form Signups
| Status | Future |
|---|---|
| Misc Member Notes | Previous EM: [email protected] 2/26/2020 MT ExMail 2/26/2020, ExMail 4/8/21, ExMail 05/13/22, ExMail 06/21/23, ExMail 07/18/24, ExMail 08/20/2025, |
| 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. | 1755701204 |
| Your Name | William Anderson |
| Email hidden; Javascript is required. | |
| Phone | (248) 714-6337 |
| Date of Birth | 03/14/1948 |
| Referred by or Referral Code | ExMail 10/20/26 |
| Enter Office Code | DC352 |
| Administrative Code | 10DOLLARS |
| Address | 3301 Saddle Ridge Highland, MI 48357 Map It |
| Payment Method | Check |
| Payment Received | Paid |
| Total | $89.95 |
| 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 | 10/28/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 11/28/2027 |
| Membership ID Number | 1792524822 |
| 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. *** |
