Test form Signups
| Status | Future |
|---|---|
| Misc Member Notes | Is a renewal, adjusted dates/EM count, resent. 10/23/26 MT |
| 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. | DC1723991882 |
| Your Name | Marijean Wright |
| Email hidden; Javascript is required. | |
| Phone | (352) 601-1388 |
| Date of Birth | 10/31/1953 |
| Enter Office Code | A20815 |
| Address | 6223 SW 115th Street Rd Ocala, FL 34476 Map It |
| Payment Method | Credit Card |
| Credit Card | visa XXXXXXXXXXXX3870 |
| 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 | 02/19/2027 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 03/19/2028 |
| Membership ID Number | 1792760731 |
| 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. *** |
