If this is a gift please denote the name of the recipient below:

First Name

Last Name

Billing address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Date of birth *

MM

DD

YYYY

Shipping contact name

First Name

Last Name

Shipping address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

I authorize charges to my credit card for a minimum of four quarterly selections *

Yes

I understand that a $150 fee will be applied to my credit card for early termination, as well as the full retail value of any gifted incentive upon joining. *

Yes

I understand after 30 days selections that are out of stock cannot be replaced *

Yes

I authorize charges to my credit card for shipping charges and/or redirection fees *

Yes

Member contact name *

First Name

Last Name

Phone number *

(###)

###

####

Date of birth *

MM

DD

YYYY

Billing address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Shipping address

if different than billing

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

I authorize charges to my credit card for a minimum of three (3) quarterly selections *

Yes

I understand that a $100 fee will be applied to my credit card for early termination, as well as the full retail value of any gifted incentive upon joining. *

Yes

I understand that there are no customizations and pickups must be claimed within 30 days. Selections which are out of stock cannot be replaced. *

Yes

I understand that an adult signature is required for delivery and I authorize charges to my credit card for shipping charges and/or redirection fees. *

Yes