Test form Signups
| Status | Future |
|---|---|
| Misc Member Notes | 1 free month added for Laura Tournas /40026959282. 3-23-17 AK RNWL UPGRD adding Andrew 1-29-18 SS |
| 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. | 1757698175 |
| Your Name | Sally Tournas |
| Phone | (508) 398-8824 |
| Date of Birth | 11/18/1943 |
| Referred by or Referral Code | Mail Rnwl 7/13/2015, ExMail 10-17-16,ExMail 1-29-18, ExMail 2/25/19, ExMail 3/31/2020, ExMail 5/11/21, ExMail 06/06/22, ExMail 07/11/23, ExMail 08/05/24, ExMail 09/12/2025, ExMail 10/20/2026 |
| Enter Office Code | A20809 |
| Address | 16 Bellevue Ave. S Yarmouth, MA 2664 Map It |
| Payment Method | Check |
| Payment Received | Paid |
| 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 | 11/16/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 12/16/2027 |
| Membership ID Number | 1792525043 |
| 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. *** |
