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. | 1757520382 |
| Your Name | Gary Passiak |
| Email hidden; Javascript is required. | |
| Phone | (248) 542-2106 |
| Date of Birth | 04/24/1952 |
| Referred by or Referral Code | ExMail 3/20/20, ExMail 05/05/21, ExMail 6/13/22, ExMail 07/11/23, ExMail 08/13/24, ExMail 09/10/2025, ExMail 10/20/2026 |
| Enter Office Code | A22062 |
| Address | 3882 Kenmore Rd Berkley, MI 48072 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 | 11/23/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 12/23/2027 |
| Membership ID Number | 1792525349 |
| 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. *** |
