Test form Signups
| Status | Expired |
|---|---|
| Misc Member Notes | Updated address to match renewal. 09/20/2023 JC |
| Membership Type | Individual Plan ($99.95) |
| Your Name | Clifton Fulcher |
| Phone | (203) 980-8411 |
| Date of Birth | 09/29/1934 |
| Referred by or Referral Code | Fax 8-23-16 |
| Enter Office Code | 11788 |
| Address | 92 Canton Ct West Haven, CT 6516 Map It |
| Total | $99.95 |
| Plan Information | |
| Newest Membership: Programmatically pick Plan Start Date Based on either new plan or their ID number here | 08/23/2016 |
| Newest Membership: Programmatically pick Expiration Date Based on either new plan or their ID number here | 11/23/2017 |
| Membership ID Number | 20152129886 |
| Past Plan Information | this probably isn't needed there should already be additional entries |
| Resend Sign Up Email | 1 |
| HTML Block | ***After clicking submit please wait 10 seconds for the form to process. Thank you. *** |
