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 PlantRepublic@yahoo.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 PlantRepublic@yahoo.com

If you have any Questions please Contact us at 310-823-7256