Test form Signups
| Status | Future |
|---|---|
| Misc Member Notes | Member wants 3 Mcardsmember requested plan to start March 1st. Adam changed it on Feb 15th, but there was not a note in the system. 2-28-17 AKRequested 3 cards 4/2/19 EK |
| Membership Type | Family Plan ($139.95) |
| 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. | 1759172409 |
| Your Name | MARY HART-MINEMIER |
| Phone | (610) 689-8849 |
| Date of Birth | 03/04/1957 |
| List Family Members | WILLIAM A. JR. |
| Enter Office Code | 37975 |
| Administrative Code | 10DOLLARS |
| Address | 115 MEADOWCREST LN DOUGLASSVILLE, PA 19518-9614 Map It |
| Payment Method | Credit Card |
| Credit Card | mastercard XXXXXXXXXXXX6721 |
| Total | $129.95 |
| 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 | 12/08/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 01/08/2028 |
| Membership ID Number | 1792603443 |
| 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. *** |
