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Intracoastal Concierge Grocery Shopping

Please find the grocery shopping list below. Please provide as much information as possible regarding your grocery needs, quantities, brand preferences, and any other relevant information. We will complete your first grocery shopping using this list. We will then save your own personalized shopping list, so that in the future you will simply need to make changes or additions where necessary.

Customer Information

Yes No

Grocery Items

Please note – we will be flexible to your needs. Let us know if your shopping and/or delivery requirements change. If you have any questions whilst completing this form, or at any time in the future, please don’t hesitate to contact us.
Product Brand Size Qty
Produce
Product Brand Size Qty
Refrigerated Items
Product Brand Size Qty
Canned Foods
Product Brand Size Qty
Meats
Product Brand Size Qty
Dairy/Cheese
Product Brand Size Qty
Various Groceries
Product Brand Size Qty
Pets
Product Brand Size Qty
Household (medicine, kitchen, bath, office, etc.)
Product Brand Size Qty
Frozen Items
Product Brand Size Qty
Condiments/Sauces
Product Brand Size Qty
Snacks
Product Brand Size Qty
Seafood
Product Brand Size Qty
Beverages
Product Brand Size Qty
Baked Goods/Baking
Product Brand Size Qty
Baby
Product Brand Size Qty
Other

Credit Card Authorization

Please fill out this form authorizing Intracoastal Concierge, LLC to charge the credit card listed below. These charges are for the purchasing of your groceries, and/or your delivery charges.

Visa Mastercard AmEx Discover

Customer Information

Full Name s:
Phone Number:
Email Address:
Delivery Date/Time:
No
Delivery Address:
Property Management Company:
City:
and Phone Number:

Credit Card Authorization

Please fill out this form authorizing Intracoastal Concierge, LLC to charge the credit card listed below. These charges are for the purchasing of your groceries, and/or your delivery charges.

Customer’s Name:
Customer’s Phone Number:
Name on Credit Card:
Discover
Card Number:
Expiration Date:
Security Code:
Billing Address:
Card Holder’s Signature:
Date:

No I do hereby authorize Intracoastal Concierge, LLC to charge the card above for my groceries, and delivery fees associated with the processing of my order. I am signing above, acknowledging that I am the card holder under penalty of law.

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