Test form Signups
| Status | Active |
|---|---|
| Misc Member Notes | Old number: 989-644-2232 |
| 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. | 1755872851 |
| Your Name | Janice Spagnolo |
| Email hidden; Javascript is required. | |
| Phone | (998) 954-1614 |
| Date of Birth | 08/13/1954 |
| List Family Members | Salvatore |
| Referred by or Referral Code | Maryann Olter -member, done, CASH20 Renew 10/24/22 |
| Address | 5503 W Beal City Road Weidman, MI 48893 Map It |
| Payment Method | Credit Card |
| Credit Card | visa XXXXXXXXXXXX7826 |
| Total | $139.95 |
| 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 | 10/21/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 11/21/2027 |
| Membership ID Number | 1792610843 |
| Past Plan Information | this probably isn't needed there should already be additional entries |
| Resend Sign Up Email | 6 |
| HTML Block | ***After clicking submit please wait 10 seconds for the form to process. Thank you. *** |
