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. | 1757520431 |
| Your Name | Gary Munson |
| Phone | (814) 882-4802 |
| Date of Birth | 12/03/1951 |
| Referred by or Referral Code | Office Call In 6/17/2021, ExMail 6/7/22, ExMail 07/03/23, ExMail 08/30/24, ExMail 09/10/2025, ExMail 10/22/2026 |
| Enter Office Code | A14420 |
| Address | 9363 Tileyard Rd Waterford, PA 16441 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 | 11/22/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 12/22/2027 |
| Membership ID Number | 1792691895 |
| 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. *** |
