Test form Signups
| Status | Active |
|---|---|
| Misc Member Notes | Old: [email protected] |
| 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. | 1754595342 |
| Your Name | Vickie Leydig |
| Email hidden; Javascript is required. | |
| Phone | (724) 717-3094 |
| Date of Birth | 07/13/1958 |
| Referred by or Referral Code | ExMail 12-4-17, ExMail 1/7/19, ExMail 2/3/2020, ExMail 06/26/2024, ExMail 08/07/2025, ExMail 10/20/2026 |
| Enter Office Code | A13719 |
| Administrative Code | 10DOLLARS |
| Address | 196 19th St New Florence, PA 15944 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 | 10/20/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 11/20/2027 |
| Membership ID Number | 1792524998 |
| 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. *** |
