REVISED Payment Plan Form: Kook & Lima ⬇️
^^Revised to reflect Start Date of January 16, 2026
Cardholder
*
First Name
Last Name
Credit/Debit Card Number
*
Card Expiration Month
*
Please Select
01
02
03
04
05
06
07
08
09
10
11
12
Card Expiration Year
*
Please Select
2026
2027
2028
2029
2030
2031
2032
2033
3-digit CVV
*
Billing Address of Card:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
I hereby agree that my above Card may be auto-charged in the discounted amount of $997 per month, beginning JANUARY 16, 2026 and continuing on the same calendar day of each consecutive subsequent month, for a grand total of FOUR (4) payments:
Signature
*
Submit
Submit
Should be Empty: