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8 week cc authorization

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  • 1. 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 Healthy Xpress. 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 www.healthyxpress.com Phone: 1-305-393-8735 Email: info@healthyxpress.com