Test form Signups
| Status | Future |
|---|---|
| Misc Member Notes | Member responded to expiration EM saying she already renewed. I now see we missed that the dates were not correct when she renewed 10/7. Updated, resent EM. 10/20/25 EK Realized I should have added her to the list for updated cards. Added to mcard resend list 11/4/25 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. | 1759864282 |
| Your Name | Edith Kempsey |
| Email hidden; Javascript is required. | |
| Phone | (570) 874-1717 |
| Date of Birth | 12/14/1928 |
| Referred by or Referral Code | ExMail 10/22/2026 |
| Enter Office Code | A12522 |
| Address | 7 Maple Street Ashland, PA 17921 Map It |
| Payment Method | Credit Card |
| Credit Card | mastercard XXXXXXXXXXXX3151 |
| 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 | 11/22/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 12/22/2027 |
| Membership ID Number | 1792691811 |
| Past Plan Information | this probably isn't needed there should already be additional entries |
| Resend Sign Up Email | 7 |
| HTML Block | ***After clicking submit please wait 10 seconds for the form to process. Thank you. *** |
