autopayment authorization form

Name *

First Name

Last Name

Registered Address *

This will be the address that the Green Choice Rewards program will be registered to.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Billing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Authorization Agreement *

I authorize Landscape Garden Centers to automatically charge my selected payment method for recurring payments. I understand that I may cancel this authorization at any time by providing written notice.

Agree

Decline (registration will not be completed)

Date *

MM

DD

YYYY