Test form Signups
| Status | Future |
|---|---|
| Misc Member Notes | mail, echeck. 09/11/24 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. | 1760212177 |
| Your Name | Douglas Navalinsky |
| Email hidden; Javascript is required. | |
| Phone | (440) 258-9863 |
| Date of Birth | 04/15/1969 |
| List Family Members | Kim, Clayton, Anna, Mary |
| Referred by or Referral Code | Mail 09/11/24 |
| Enter Office Code | GM1008 |
| Address | 417 West 35th St Lorain, OH 44055 Map It |
| Payment Method | Credit Card |
| Credit Card | mastercard XXXXXXXXXXXX3273 |
| 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 | 11/13/2026 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 12/13/2027 |
| Membership ID Number | 1792968464 |
| 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. *** |
