CREDIT CARD AUTHORIZATION FORM
I __________________________________ hereby authorize Healthy Xpress to charge the credit card
(Name of cardholder as it appears on credit card) noted below to satisfy all debts accrued. The authorization and the
information found within are to be used as follows.(Please check box below)
I hereby authorize weekly recurring payments for the value of my order(s).
Customer will select a plan below, and commit to 4 or 8 weeks to receive special rate from Healthy Xpress.
If customer does not purchase the amount of weeks below, and cancels he/she will be responsible to pay for
the discounts applied.
SELECT A PLAN BELOW
_____ PALEO MEAL PLAN x 4 WEEKS $125wk
_____ HEALTHY LUNCH x 4 WEEKS $45 wk
______ PALEO MEAL PLAN x 8 WEEKS $115 wk
_______ HEALTHY LUNCH x 8 WEEKS $42 wk
______ HEALTHY LUNCH &DINNER x 4 WEEKS $75 wk ______ HEALTHY LUNCH & DINNER x 8 WEEKS $68 wk
* Please leave bags out for driver to pick up on delivery days, if not you will be charged additional $10 per bag you do not return to
Credit Card Information
Credit Card Type: Visa ___ Master Card___ Discover___ American Express _____
Card Number: ______________________________ Expiration Date: __________
CVC/CVV2 (Code in back of card (3-digits o 4 digits for AMEX): _______________
Billing Address: ________________________________________ Zip Code: _______
Shipping Address: ________________________________________ Zip Code: _______
Email*: _____________________________________ Cell Phone*:______________________
Authorizing Signature: _____________________ _____Date: _____________
I attest to the above information being true to the best of my knowledge. The customer will be responsible for any chargeback
charges. Charges will show as Geodinamica LLC dba Healthy Xpress.
* I authorize Healthy Xpress to send me promotions via email or Text Message by providing this information.
Delivering A Healthy Lifestyle
Phone: 1-305-393-8735 Email: firstname.lastname@example.org