Test form Signups
| Status | Future |
|---|---|
| Misc Member Notes | ExMail was dated 10/15, I was out sick last week and Mel on vacation. Processed today. Can probably back date to 10/15 if for some reason it is necessary. 10/20/25 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. | 1760966001 |
| Your Name | Betty Sisson |
| Phone | (607) 437-3706 |
| Date of Birth | 07/06/1940 |
| Referred by or Referral Code | Office call in 09/10/24, ExMail 10/20/25, ExMail 10/22/2026 |
| Enter Office Code | 29775 |
| Address | PO Box 52 Maryland, NY 12116 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 | 11/21/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 12/21/2027 |
| Membership ID Number | 1792691941 |
| Past Plan Information | this probably isn't needed there should already be additional entries |
| Resend Sign Up Email | 3 |
| HTML Block | ***After clicking submit please wait 10 seconds for the form to process. Thank you. *** |
