Test form Signups
| Status | Future |
|---|---|
| Misc Member Notes | DLN: Szikman 12/06/24 JC |
| Membership Type | Family Plan ($139.95) |
| 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. | DC1764691231 |
| Your Name | William E Porter |
| Email hidden; Javascript is required. | |
| Phone | (706) 579-1721 |
| Date of Birth | 08/27/1948 |
| List Family Members | Mary B. |
| Address | 10792 Big Canoe Jasper, GA 30143 Map It |
| Payment Method | Credit Card |
| Credit Card | visa XXXXXXXXXXXX5707 |
| Total | $139.95 |
| 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 | 02/15/2027 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 03/15/2028 |
| Membership ID Number | 1792966885 |
| Past Plan Information | this probably isn't needed there should already be additional entries |
| Resend Sign Up Email | 8 |
| HTML Block | ***After clicking submit please wait 10 seconds for the form to process. Thank you. *** |
