Test form Signups
| Status | Future |
|---|---|
| Misc Member Notes | Fixed the dates and resent EM 9/26/25 |
| 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. | 1758841787 |
| Your Name | Rebecca Goscha |
| Email hidden; Javascript is required. | |
| Phone | (402) 679-1875 |
| Date of Birth | 05/23/1959 |
| Enter Office Code | 26563 |
| Address | 214 S Allen St PO BOX 336 Bennington, NE 68007 Map It |
| Payment Method | Credit Card |
| Credit Card | mastercard XXXXXXXXXXXX4005 |
| 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 | 05/22/2027 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 06/22/2028 |
| Membership ID Number | 1793030643 |
| Past Plan Information | this probably isn't needed there should already be additional entries |
| Resend Sign Up Email | 4 |
| HTML Block | ***After clicking submit please wait 10 seconds for the form to process. Thank you. *** |
