All required fields are marked with an asterisk (*).
Your card will automatically be charged $35.75 every 13 weeks until you notify us otherwise.
Your card will automatically be charged $13.00 every 13 weeks until you notify us otherwise.
Your card will automatically be charged $12.87 every 13 weeks until you notify us otherwise.
Your card will be charged $35.75 for the first billing period, after which you will receive a bill every 13 weeks.
Your card will be charged $13.00 for the first billing period, after which you will receive a bill every 13 weeks.
Your card will be charged $12.87 for the first billing period, after which you will receive a bill every 13 weeks.
Your card will be charged $143.00 for the first 52 weeks.
Your card will be charged $26.00 for the first 26 weeks.
Your card will be charged $51.48 for the first 52 weeks.
If the billing information is different from the delivery information above please complete the following.