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.