Plant Republic - Credit Card Authorization Form

Plant Republic Credit Card Authorization Form

Instructions:
1. Please fill out the information below and Print this form.
2. Sign where indicated
3. Submit in Person or by Scan & Email to info@MyPlantopia.com

Cardholder Name:

Credit Card (choose one):

MasterCard Visa Discover American Express

Card Number:

Security Code:

This 3-digit Number is located on the back side of your card

Expiration Date:

/ MM/YY

Credit Card Billing Address:

Street:		Suite#:
City:		State:
Zip Code:

Telephone:

E-mail Address:

I authorize Plant Republic Inc. to charge
my credit card in the amount of:

Transaction Frequency:

Monthly Recurring Fee for Interior Plant Service One Time Only

Authorization Date: _______________________

Signature: _______________________________________________________

Fax signed form to:
Submit in Person or by Email info@MyPlantopia.com

If you have any Questions please Contact us at