Test form Signups
| Status | Future |
|---|---|
| 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. | 1760965901 |
| Your Name | James A Wilson |
| Email hidden; Javascript is required. | |
| Phone | (216) 939-0739 |
| Date of Birth | 09/04/1957 |
| Referred by or Referral Code | ExMail 3-19-18, ExMail 4/15/19, ExMail 4/14/2020, ExMail 05/13/21, ExMail 06/14/22, ExMail 8/14/23, ExMail 09/13/2024, ExMail 10/20/25, ExMail 10/20/2026 |
| Address | 2173 West 105 St Cleveland, OH 44102 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 | 12/04/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 01/04/2028 |
| Membership ID Number | 1792525273 |
| 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. *** |
