Test form Signups
| Status | Future |
|---|---|
| Misc Member Notes | Member already renewed 12/7/2021 but we rcv’d check in the mail today. Called member, rang for a long time and reached disconnected sound. Will try again later. 1/4/2022 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. | 1759930288 |
| Your Name | Jean G Sanderson |
| Phone | (203) 314-6736 |
| Date of Birth | 01/21/1949 |
| Referred by or Referral Code | ExMail 10/20/2026 |
| Enter Office Code | 11788 |
| Address | 71 Glen Pkwy Hamden, CT 6517 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 | 11/09/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 12/09/2027 |
| Membership ID Number | 1792525206 |
| Past Plan Information | this probably isn't needed there should already be additional entries |
| Resend Sign Up Email | 7 |
| HTML Block | ***After clicking submit please wait 10 seconds for the form to process. Thank you. *** |
