Healthy Xpress Paleo Specials for current customers

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 ___
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.
CREDIT CARD AUTHORIZATIONFORM
I __________________________________ herebyauthorize Healthy Xpress to
charge the credit card (Name ofcardholder as it appears on creditcard) 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 weeklyrecurring payments for the value of my order(s).
Customer will select a plan below, and commit to 4 or 8 weeks to receiv e special rate f rom Healthy Xpress. If customer does not
purchase the amount of weeks below, and cancels he/she will be responsible to pay f or the discounts applied. Af ter my commitment is
ov er, I authorize Healthy Xpress to charge my card on a weekly basis unless I email to cancel the Friday bef ore the week of s erv ice by
6pm.
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)
_____ $525 (SAVE 16%) (4 weeks – paid upfront, use 1 week at time, no expiration or commitment) +Free bottle
of GButter +HX – T-shirt
_____ PALEO FULL MEAL PLAN x 4 WEEKS $140 wk _____ PALEO FULL MEAL PLAN x 8 WEEKS $135 wk
_____ PALEO 2 Meals x 4 WEEKS $100 / wk _____ PALEO 2 Meals x 8 WEEKS $95 / wk
_$30_ Cooler Bag & Ice pack (optional) (bag is yours to keep after the service is over.)
Other wise deliveredinplastic – HX is not responsible if you choose not to get our bags if food moves
around during transportation or food is not kept in temperature after delivery.)
A. Refund of $20 occurs when customer has returned 4 out of 5 bags on lastdelivery day.
B. Refund of $15 occurs if customer requests pick up of bags after lastdelivery is done.
C. Refund of $0 occurs if customer keeps more than 1 bag after lastdelivery day and does not request pick up
bags.
_____ 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: ______________________________________________ ZipCode: __________
Shipping Address: ____________________________________________ Zip Code: __________
Email*: _______________________________________ Cell Phone*:______________________
Authorizing Signature: _________________________________________ Date:____________