Email: __________________ Cell Phone: ______________
Delivering a Healthy Lifestyle
www.healthyxpress.com Phone: 1-305-393...
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Credit Card Authorization All

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Credit Card Authorization All

  1. 1. Email: __________________ Cell Phone: ______________ Delivering a Healthy Lifestyle www.healthyxpress.com Phone: 1-305-393-.8735 Email: info@healthyxpress.com OFFICE USE ONLY: CRM ____ QB _____ RT _____ PD ______ EMAIL______ 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 one box below) I hereby authorize a onetime service payment in the amount of my order $_______________. ___$20___ Cooler Bag & Ice pack (optional) (bag is yours to keep after the service is over.) _________ Tip (you will have same driver every day) __________ TOTAL I hereby authorize a weekly service payment in the amount of my order $_______________. ___$20___ Cooler Bag & Ice pack (optional) (bag is yours to keep after the service is over.) _________ Tip (you will have same driver every day) __________ TOTAL Credit Card Information Credit Card Type: Visa ____ Master Card___ Discover___ American Express _____ Cash ______ Name on Card __________________________________ Card Number: ______________________________ Expiration Date: __________ CVV _________ Shipping Address: ________________________________________ Zip Code: _______ Billing Address: ________________________________________ Zip Code: _______ Delivery Instructions: ________________________________________________________ Authorizing Signature: _____________________ _____ Date: _____________ I am allergic to/don’t eat: _______________________________________________________ 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.

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