Test form Signups
| Status | Future |
|---|---|
| Misc Member Notes | Never received Mcards, resend 4/4/19 EK |
| 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. | 1758732707 |
| Your Name | Shirley J Barner |
| Phone | (717) 444-3757 |
| Date of Birth | 03/04/1938 |
| Referred by or Referral Code | Mail 9-14-15, ExMail 11-22-16, ExMail 1-30-18, ExMail 2/25/19, ExMail 5/4/20, ExMail 5/11/21, ExMail 7/19/23, ExMail 08/07/2024, ExMail 09/24/2025, ExMail 10/20/2026 |
| Enter Office Code | A12789 |
| Address | 200 Valley View Rd Millerstown, PA 17062 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 | 11/21/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 12/21/2027 |
| Membership ID Number | 1792525310 |
| 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. *** |
