Test form Signups
| Status | Future |
|---|---|
| Misc Member Notes | Jean called for EN's in the area. I gave her a couple. One of them (Martina Gerges EN 34614 in QB) called to verify her and they understood the billing. Should be all good 🙂 11/20/25 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. | 1763580740 |
| Your Name | Jean Kotsybar |
| Phone | (216) 544-8222 |
| Date of Birth | 10/31/1952 |
| Enter Office Code | GM4975 |
| Address | 4724 S Hills Dr Cleveland, OH 44109 Map It |
| Payment Method | Credit Card |
| Credit Card | visa XXXXXXXXXXXX4201 |
| 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 | 12/20/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 01/20/2028 |
| Membership ID Number | 1792778353 |
| Past Plan Information | this probably isn't needed there should already be additional entries |
| Resend Sign Up Email | 2 |
| HTML Block | ***After clicking submit please wait 10 seconds for the form to process. Thank you. *** |
