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Balanced Meal Specials
- 1. Delivering A Healthy Lifestyle www.healthyxpress.com Phone: 1-305-393-8735 Email: info@healthyxpress.com OFFICE USE ONLY: REP _____ CRM ____ QB _____ RT _____ PD ______ EMAIL______ VOUCHER ___ 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. 1. SELECT A PLAN BELOW 2. VIEW OPTIONS 3. TOTAL YOUR AUTHORIZED WEEKLY PAYMENT (BAG IS ONLY CHARGED DURING THE FIRST WEEK OF YOUR ORDER) _$20_ Cooler Bag & Ice pack (optional) (bag is yours to keep after the service is over.) * Please leave bags out for driver on delivery days. Each bag not returned will incur a $10 charge per bag. _____ Tip (you will have same driver every day) _____ TOTAL 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. Healthy Cantina/Balanced Meals Regular Rate 4 Weeks /wk Savings 8 Weeks/wk Savings Upfront 4 Weeks Lunch 51.5 47.85 7% 45 13% 180 Lunch & Dinner 91.5 85 7% 80 13% 320