Clone of REVISED Payment Plan Form: Kook & Lima ⬇️

Jan 12th Payment Plan Form: Bodiford ⬇️
Cardholder*

First NameLast Name
Credit/Debit Card Number*
Card Expiration Month*
Card Expiration Year*
3-digit CVV*
Billing Address of Card:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I hereby agree that my above Card may be auto-charged in the discounted amount of $2634 beginning JANUARY 12, 2026 and the same amount again on FEBRUARY 12, 2026, for a grand total of TWO (2) payments:
Signature*
Should be Empty:

Jan 12th Payment Plan Form: Bodiford ⬇️