AmEx

CREDIT CARD RECURRING BILLING CONSENT FORM

NOTE: This is not a secure document. You may complete it online, print it and fax it to us at
(305) 251-9825. Please sign and date the printed form to the right of the 'reset' button.

Name as it appears on your card Account name (if different)

American Express Master Card Visa

Credit card number

Expiration date

Billing Address City State Zip code

Please select ONE statement below

I authorize Fosterplants, Inc. to charge the amount of my monthly recurring service fee to the above referenced card.
I authorize Fosterplants, Inc. to charge the amount of my monthly recurring service fee and any authorized add-on purchases to the above referenced card.

Please select ONE statement below

My Credit Card statement will serve as my receipt.
I would like to be sent a Fosterplants invoice or statement.

I agree to allow Fosterplants, Inc. to process recurring monthly charges to my listed credit card account listed above. I understand that these charges will be entered by the tenth (10th) day of each service month. I may request a cancellation of this billing option at any time by notifying Fosterplants via fax at (305) 251-9825.

I understand that if there is an outstanding balance on my account, this amount will be processed with the first recurring charge.

Signature: