Shopper Trial Box Form – Phood Community Farm

1. Order details

2. Account information

3. Checkout

Number of persons:

How many people will the Phood box be for?

Phoodbox pickup or delivery:

Do you live within a 4km radius? Then we can also have the Phoodbox delivered to you for €2.99!

Aantal personen

Phoodbox ophalen of bezorgen

Frequentie Phoodbox

Timeslot ophalen

Betalingswijze

Bezorgkosten Phoodbox

Totaal nu te betalen

Controleer je gegevens

Ga terug om aan te passen

Contactgegevens

E-mail:

Telefoon:

Voornaam:

Achternaam:

Factuuradres

Straat:

Huisnummer:

Toevoeging:

Postcode:

Woonplaats:

Opmerking

Opmerking:

Betaalmethode:

Betaal veilig met je Credit card of IBAN via Stripe Checkout

Betaal met je bankpas via Ideal

Akkoord automatische incasso:

Hierbij geef ik akkoord om mijn abonnement per automatische incasso te incasseren.

Price:

€23.50

First Name: First Name Required

Last Name: Last Name Required

Address Line 1:* Address Line 1 is Required

Address Line 2: Address Line 2 is not valid

City:* City is Required

Country:* Country is Required

State/Province:* State/Province is Required

Zip/Postal Code:* Zip/Postal Code is Required

Phoodbox ophalen of bezorgen: Phoodbox ophalen of bezorgen is not valid

Timeslot for Ophalen: Timeslot for Ophalen is not valid

Timeslot for Bezorgen: Timeslot for Bezorgen is not valid

Frequentie Phoodbox: Frequentie Phoodbox is not valid

Phoodbox pickup by someone: Phoodbox pickup by someone is not valid

Telefoon: Telefoon is not valid

Voornaam: Voornaam is not valid

Achternaam: Achternaam is not valid

Postcode: Postcode is not valid

Different delivery address: Different delivery address is not valid

Phoodbox address street: Phoodbox address street is not valid

Phoodbox address housenumber: Phoodbox address housenumber is not valid

Phoodbox address additional: Phoodbox address additional is not valid

Phoodbox address residance: Phoodbox address residance is not valid

Phoodbox delivery date: Phoodbox delivery date is not valid

Address additional: Address additional is not valid

Recurring payment enable: Recurring payment enable is not valid

User Telefoon:* User Telefoon is Required

User Comment: User Comment is not valid

Email:* Invalid Email

Password:* Invalid Password

Password Confirmation:* Wachtwoordbevestiging komt niet overeen

Have a coupon?

Coupon Code:

Invalid Coupon

Stripe Payments

Pay with your Credit Card via Stripe Checkout

Javascript is disabled in your browser. You will not be able to complete your purchase until you either enable JavaScript in your browser, or switch to a browser that supports it.

Ik heb de gebruikersvoorwaarden en het privacy-beleid gelezen en ga hiermee akkoord.*

No val Please fix the errors above

Price:

€47

First Name: First Name Required

Last Name: Last Name Required

Address Line 1:* Address Line 1 is Required

Address Line 2: Address Line 2 is not valid

City:* City is Required

Country:* Country is Required

State/Province:* State/Province is Required

Zip/Postal Code:* Zip/Postal Code is Required

Phoodbox ophalen of bezorgen: Phoodbox ophalen of bezorgen is not valid

Timeslot for Ophalen: Timeslot for Ophalen is not valid

Timeslot for Bezorgen: Timeslot for Bezorgen is not valid

Frequentie Phoodbox: Frequentie Phoodbox is not valid

Phoodbox pickup by someone: Phoodbox pickup by someone is not valid

Telefoon: Telefoon is not valid

Voornaam: Voornaam is not valid

Achternaam: Achternaam is not valid

Postcode: Postcode is not valid

Different delivery address: Different delivery address is not valid

Phoodbox address street: Phoodbox address street is not valid

Phoodbox address housenumber: Phoodbox address housenumber is not valid

Phoodbox address additional: Phoodbox address additional is not valid

Phoodbox address residance: Phoodbox address residance is not valid

Phoodbox delivery date: Phoodbox delivery date is not valid

Address additional: Address additional is not valid

Recurring payment enable: Recurring payment enable is not valid

User Telefoon:* User Telefoon is Required

User Comment: User Comment is not valid

Email:* Invalid Email

Password:* Invalid Password

Password Confirmation:* Wachtwoordbevestiging komt niet overeen

Have a coupon?

Coupon Code:

Invalid Coupon

Stripe Payments

Pay with your Credit Card via Stripe Checkout

Javascript is disabled in your browser. You will not be able to complete your purchase until you either enable JavaScript in your browser, or switch to a browser that supports it.

Ik heb de gebruikersvoorwaarden en het privacy-beleid gelezen en ga hiermee akkoord.*

No val Please fix the errors above

Price:

€70.50

First Name: First Name Required

Last Name: Last Name Required

Address Line 1:* Address Line 1 is Required

Address Line 2: Address Line 2 is not valid

City:* City is Required

Country:* Country is Required

State/Province:* State/Province is Required

Zip/Postal Code:* Zip/Postal Code is Required

Phoodbox ophalen of bezorgen: Phoodbox ophalen of bezorgen is not valid

Timeslot for Ophalen: Timeslot for Ophalen is not valid

Timeslot for Bezorgen: Timeslot for Bezorgen is not valid

Frequentie Phoodbox: Frequentie Phoodbox is not valid

Phoodbox pickup by someone: Phoodbox pickup by someone is not valid

Telefoon: Telefoon is not valid

Voornaam: Voornaam is not valid

Achternaam: Achternaam is not valid

Postcode: Postcode is not valid

Different delivery address: Different delivery address is not valid

Phoodbox address street: Phoodbox address street is not valid

Phoodbox address housenumber: Phoodbox address housenumber is not valid

Phoodbox address additional: Phoodbox address additional is not valid

Phoodbox address residance: Phoodbox address residance is not valid

Phoodbox delivery date: Phoodbox delivery date is not valid

Address additional: Address additional is not valid

Recurring payment enable: Recurring payment enable is not valid

User Telefoon:* User Telefoon is Required

User Comment: User Comment is not valid

Email:* Invalid Email

Password:* Invalid Password

Password Confirmation:* Wachtwoordbevestiging komt niet overeen

Have a coupon?

Coupon Code:

Invalid Coupon

Stripe Payments

Pay with your Credit Card via Stripe Checkout

Javascript is disabled in your browser. You will not be able to complete your purchase until you either enable JavaScript in your browser, or switch to a browser that supports it.

Ik heb de gebruikersvoorwaarden en het privacy-beleid gelezen en ga hiermee akkoord.*

No val Please fix the errors above

Price:

€94

First Name: First Name Required

Last Name: Last Name Required

Address Line 1:* Address Line 1 is Required

Address Line 2: Address Line 2 is not valid

City:* City is Required

Country:* Country is Required

State/Province:* State/Province is Required

Zip/Postal Code:* Zip/Postal Code is Required

Phoodbox ophalen of bezorgen: Phoodbox ophalen of bezorgen is not valid

Timeslot for Ophalen: Timeslot for Ophalen is not valid

Timeslot for Bezorgen: Timeslot for Bezorgen is not valid

Frequentie Phoodbox: Frequentie Phoodbox is not valid

Phoodbox pickup by someone: Phoodbox pickup by someone is not valid

Telefoon: Telefoon is not valid

Voornaam: Voornaam is not valid

Achternaam: Achternaam is not valid

Postcode: Postcode is not valid

Different delivery address: Different delivery address is not valid

Phoodbox address street: Phoodbox address street is not valid

Phoodbox address housenumber: Phoodbox address housenumber is not valid

Phoodbox address additional: Phoodbox address additional is not valid

Phoodbox address residance: Phoodbox address residance is not valid

Phoodbox delivery date: Phoodbox delivery date is not valid

Address additional: Address additional is not valid

Recurring payment enable: Recurring payment enable is not valid

User Telefoon:* User Telefoon is Required

User Comment: User Comment is not valid

Email:* Invalid Email

Password:* Invalid Password

Password Confirmation:* Wachtwoordbevestiging komt niet overeen

Have a coupon?

Coupon Code:

Invalid Coupon

Stripe Payments

Pay with your Credit Card via Stripe Checkout

Javascript is disabled in your browser. You will not be able to complete your purchase until you either enable JavaScript in your browser, or switch to a browser that supports it.

Ik heb de gebruikersvoorwaarden en het privacy-beleid gelezen en ga hiermee akkoord.*

No val Please fix the errors above

Price:

€117.50

First Name: First Name Required

Last Name: Last Name Required

Address Line 1:* Address Line 1 is Required

Address Line 2: Address Line 2 is not valid

City:* City is Required

Country:* Country is Required

State/Province:* State/Province is Required

Zip/Postal Code:* Zip/Postal Code is Required

Phoodbox ophalen of bezorgen: Phoodbox ophalen of bezorgen is not valid

Timeslot for Ophalen: Timeslot for Ophalen is not valid

Timeslot for Bezorgen: Timeslot for Bezorgen is not valid

Frequentie Phoodbox: Frequentie Phoodbox is not valid

Phoodbox pickup by someone: Phoodbox pickup by someone is not valid

Telefoon: Telefoon is not valid

Voornaam: Voornaam is not valid

Achternaam: Achternaam is not valid

Postcode: Postcode is not valid

Different delivery address: Different delivery address is not valid

Phoodbox address street: Phoodbox address street is not valid

Phoodbox address housenumber: Phoodbox address housenumber is not valid

Phoodbox address additional: Phoodbox address additional is not valid

Phoodbox address residance: Phoodbox address residance is not valid

Phoodbox delivery date: Phoodbox delivery date is not valid

Address additional: Address additional is not valid

Recurring payment enable: Recurring payment enable is not valid

User Telefoon:* User Telefoon is Required

User Comment: User Comment is not valid

Email:* Invalid Email

Password:* Invalid Password

Password Confirmation:* Wachtwoordbevestiging komt niet overeen

Have a coupon?

Coupon Code:

Invalid Coupon

Stripe Payments

Pay with your Credit Card via Stripe Checkout

Javascript is disabled in your browser. You will not be able to complete your purchase until you either enable JavaScript in your browser, or switch to a browser that supports it.

Ik heb de gebruikersvoorwaarden en het privacy-beleid gelezen en ga hiermee akkoord.*

No val Please fix the errors above

Price:

€141

First Name: First Name Required

Last Name: Last Name Required

Address Line 1:* Address Line 1 is Required

Address Line 2: Address Line 2 is not valid

City:* City is Required

Country:* Country is Required

State/Province:* State/Province is Required

Zip/Postal Code:* Zip/Postal Code is Required

Phoodbox ophalen of bezorgen: Phoodbox ophalen of bezorgen is not valid

Timeslot for Ophalen: Timeslot for Ophalen is not valid

Timeslot for Bezorgen: Timeslot for Bezorgen is not valid

Frequentie Phoodbox: Frequentie Phoodbox is not valid

Phoodbox pickup by someone: Phoodbox pickup by someone is not valid

Telefoon: Telefoon is not valid

Voornaam: Voornaam is not valid

Achternaam: Achternaam is not valid

Postcode: Postcode is not valid

Different delivery address: Different delivery address is not valid

Phoodbox address street: Phoodbox address street is not valid

Phoodbox address housenumber: Phoodbox address housenumber is not valid

Phoodbox address additional: Phoodbox address additional is not valid

Phoodbox address residance: Phoodbox address residance is not valid

Phoodbox delivery date: Phoodbox delivery date is not valid

Address additional: Address additional is not valid

Recurring payment enable: Recurring payment enable is not valid

User Telefoon:* User Telefoon is Required

User Comment: User Comment is not valid

Email:* Invalid Email

Password:* Invalid Password

Password Confirmation:* Wachtwoordbevestiging komt niet overeen

Have a coupon?

Coupon Code:

Invalid Coupon

Stripe Payments

Pay with your Credit Card via Stripe Checkout

Javascript is disabled in your browser. You will not be able to complete your purchase until you either enable JavaScript in your browser, or switch to a browser that supports it.

Ik heb de gebruikersvoorwaarden en het privacy-beleid gelezen en ga hiermee akkoord.*

No val Please fix the errors above

Price:

€26.49

First Name: First Name Required

Last Name: Last Name Required

Address Line 1:* Address Line 1 is Required

Address Line 2: Address Line 2 is not valid

City:* City is Required

Country:* Country is Required

State/Province:* State/Province is Required

Zip/Postal Code:* Zip/Postal Code is Required

Phoodbox ophalen of bezorgen: Phoodbox ophalen of bezorgen is not valid

Timeslot for Ophalen: Timeslot for Ophalen is not valid

Timeslot for Bezorgen: Timeslot for Bezorgen is not valid

Frequentie Phoodbox: Frequentie Phoodbox is not valid

Phoodbox pickup by someone: Phoodbox pickup by someone is not valid

Telefoon: Telefoon is not valid

Voornaam: Voornaam is not valid

Achternaam: Achternaam is not valid

Postcode: Postcode is not valid

Different delivery address: Different delivery address is not valid

Phoodbox address street: Phoodbox address street is not valid

Phoodbox address housenumber: Phoodbox address housenumber is not valid

Phoodbox address additional: Phoodbox address additional is not valid

Phoodbox address residance: Phoodbox address residance is not valid

Phoodbox delivery date: Phoodbox delivery date is not valid

Address additional: Address additional is not valid

Recurring payment enable: Recurring payment enable is not valid

User Telefoon:* User Telefoon is Required

User Comment: User Comment is not valid

Email:* Invalid Email

Password:* Invalid Password

Password Confirmation:* Wachtwoordbevestiging komt niet overeen

Have a coupon?

Coupon Code:

Invalid Coupon

Stripe Payments

Pay with your Credit Card via Stripe Checkout

Javascript is disabled in your browser. You will not be able to complete your purchase until you either enable JavaScript in your browser, or switch to a browser that supports it.

Ik heb de gebruikersvoorwaarden en het privacy-beleid gelezen en ga hiermee akkoord.*

No val Please fix the errors above

Price:

€49.99

First Name: First Name Required

Last Name: Last Name Required

Address Line 1:* Address Line 1 is Required

Address Line 2: Address Line 2 is not valid

City:* City is Required

Country:* Country is Required

State/Province:* State/Province is Required

Zip/Postal Code:* Zip/Postal Code is Required

Phoodbox ophalen of bezorgen: Phoodbox ophalen of bezorgen is not valid

Timeslot for Ophalen: Timeslot for Ophalen is not valid

Timeslot for Bezorgen: Timeslot for Bezorgen is not valid

Frequentie Phoodbox: Frequentie Phoodbox is not valid

Phoodbox pickup by someone: Phoodbox pickup by someone is not valid

Telefoon: Telefoon is not valid

Voornaam: Voornaam is not valid

Achternaam: Achternaam is not valid

Postcode: Postcode is not valid

Different delivery address: Different delivery address is not valid

Phoodbox address street: Phoodbox address street is not valid

Phoodbox address housenumber: Phoodbox address housenumber is not valid

Phoodbox address additional: Phoodbox address additional is not valid

Phoodbox address residance: Phoodbox address residance is not valid

Phoodbox delivery date: Phoodbox delivery date is not valid

Address additional: Address additional is not valid

Recurring payment enable: Recurring payment enable is not valid

User Telefoon:* User Telefoon is Required

User Comment: User Comment is not valid

Email:* Invalid Email

Password:* Invalid Password

Password Confirmation:* Wachtwoordbevestiging komt niet overeen

Have a coupon?

Coupon Code:

Invalid Coupon

Stripe Payments

Pay with your Credit Card via Stripe Checkout

Javascript is disabled in your browser. You will not be able to complete your purchase until you either enable JavaScript in your browser, or switch to a browser that supports it.

Ik heb de gebruikersvoorwaarden en het privacy-beleid gelezen en ga hiermee akkoord.*

No val Please fix the errors above

Price:

€73.49

First Name: First Name Required

Last Name: Last Name Required

Address Line 1:* Address Line 1 is Required

Address Line 2: Address Line 2 is not valid

City:* City is Required

Country:* Country is Required

State/Province:* State/Province is Required

Zip/Postal Code:* Zip/Postal Code is Required

Phoodbox ophalen of bezorgen: Phoodbox ophalen of bezorgen is not valid

Timeslot for Ophalen: Timeslot for Ophalen is not valid

Timeslot for Bezorgen: Timeslot for Bezorgen is not valid

Frequentie Phoodbox: Frequentie Phoodbox is not valid

Phoodbox pickup by someone: Phoodbox pickup by someone is not valid

Telefoon: Telefoon is not valid

Voornaam: Voornaam is not valid

Achternaam: Achternaam is not valid

Postcode: Postcode is not valid

Different delivery address: Different delivery address is not valid

Phoodbox address street: Phoodbox address street is not valid

Phoodbox address housenumber: Phoodbox address housenumber is not valid

Phoodbox address additional: Phoodbox address additional is not valid

Phoodbox address residance: Phoodbox address residance is not valid

Phoodbox delivery date: Phoodbox delivery date is not valid

Address additional: Address additional is not valid

Recurring payment enable: Recurring payment enable is not valid

User Telefoon:* User Telefoon is Required

User Comment: User Comment is not valid

Email:* Invalid Email

Password:* Invalid Password

Password Confirmation:* Wachtwoordbevestiging komt niet overeen

Have a coupon?

Coupon Code:

Invalid Coupon

Stripe Payments

Pay with your Credit Card via Stripe Checkout

Javascript is disabled in your browser. You will not be able to complete your purchase until you either enable JavaScript in your browser, or switch to a browser that supports it.

Ik heb de gebruikersvoorwaarden en het privacy-beleid gelezen en ga hiermee akkoord.*

No val Please fix the errors above

Price:

€96.99

First Name: First Name Required

Last Name: Last Name Required

Address Line 1:* Address Line 1 is Required

Address Line 2: Address Line 2 is not valid

City:* City is Required

Country:* Country is Required

State/Province:* State/Province is Required

Zip/Postal Code:* Zip/Postal Code is Required

Phoodbox ophalen of bezorgen: Phoodbox ophalen of bezorgen is not valid

Timeslot for Ophalen: Timeslot for Ophalen is not valid

Timeslot for Bezorgen: Timeslot for Bezorgen is not valid

Frequentie Phoodbox: Frequentie Phoodbox is not valid

Phoodbox pickup by someone: Phoodbox pickup by someone is not valid

Telefoon: Telefoon is not valid

Voornaam: Voornaam is not valid

Achternaam: Achternaam is not valid

Postcode: Postcode is not valid

Different delivery address: Different delivery address is not valid

Phoodbox address street: Phoodbox address street is not valid

Phoodbox address housenumber: Phoodbox address housenumber is not valid

Phoodbox address additional: Phoodbox address additional is not valid

Phoodbox address residance: Phoodbox address residance is not valid

Phoodbox delivery date: Phoodbox delivery date is not valid

Address additional: Address additional is not valid

Recurring payment enable: Recurring payment enable is not valid

User Telefoon:* User Telefoon is Required

User Comment: User Comment is not valid

Email:* Invalid Email

Password:* Invalid Password

Password Confirmation:* Wachtwoordbevestiging komt niet overeen

Have a coupon?

Coupon Code:

Invalid Coupon

Stripe Payments

Pay with your Credit Card via Stripe Checkout

Javascript is disabled in your browser. You will not be able to complete your purchase until you either enable JavaScript in your browser, or switch to a browser that supports it.

Ik heb de gebruikersvoorwaarden en het privacy-beleid gelezen en ga hiermee akkoord.*

No val Please fix the errors above

Price:

€120.49

First Name: First Name Required

Last Name: Last Name Required

Address Line 1:* Address Line 1 is Required

Address Line 2: Address Line 2 is not valid

City:* City is Required

Country:* Country is Required

State/Province:* State/Province is Required

Zip/Postal Code:* Zip/Postal Code is Required

Phoodbox ophalen of bezorgen: Phoodbox ophalen of bezorgen is not valid

Timeslot for Ophalen: Timeslot for Ophalen is not valid

Timeslot for Bezorgen: Timeslot for Bezorgen is not valid

Frequentie Phoodbox: Frequentie Phoodbox is not valid

Phoodbox pickup by someone: Phoodbox pickup by someone is not valid

Telefoon: Telefoon is not valid

Voornaam: Voornaam is not valid

Achternaam: Achternaam is not valid

Postcode: Postcode is not valid

Different delivery address: Different delivery address is not valid

Phoodbox address street: Phoodbox address street is not valid

Phoodbox address housenumber: Phoodbox address housenumber is not valid

Phoodbox address additional: Phoodbox address additional is not valid

Phoodbox address residance: Phoodbox address residance is not valid

Phoodbox delivery date: Phoodbox delivery date is not valid

Address additional: Address additional is not valid

Recurring payment enable: Recurring payment enable is not valid

User Telefoon:* User Telefoon is Required

User Comment: User Comment is not valid

Email:* Invalid Email

Password:* Invalid Password

Password Confirmation:* Wachtwoordbevestiging komt niet overeen

Have a coupon?

Coupon Code:

Invalid Coupon

Stripe Payments

Pay with your Credit Card via Stripe Checkout

Javascript is disabled in your browser. You will not be able to complete your purchase until you either enable JavaScript in your browser, or switch to a browser that supports it.

Ik heb de gebruikersvoorwaarden en het privacy-beleid gelezen en ga hiermee akkoord.*

No val Please fix the errors above

Price:

€143.99

First Name: First Name Required

Last Name: Last Name Required

Address Line 1:* Address Line 1 is Required

Address Line 2: Address Line 2 is not valid

City:* City is Required

Country:* Country is Required

State/Province:* State/Province is Required

Zip/Postal Code:* Zip/Postal Code is Required

Phoodbox ophalen of bezorgen: Phoodbox ophalen of bezorgen is not valid

Timeslot for Ophalen: Timeslot for Ophalen is not valid

Timeslot for Bezorgen: Timeslot for Bezorgen is not valid

Frequentie Phoodbox: Frequentie Phoodbox is not valid

Phoodbox pickup by someone: Phoodbox pickup by someone is not valid

Telefoon: Telefoon is not valid

Voornaam: Voornaam is not valid

Achternaam: Achternaam is not valid

Postcode: Postcode is not valid

Different delivery address: Different delivery address is not valid

Phoodbox address street: Phoodbox address street is not valid

Phoodbox address housenumber: Phoodbox address housenumber is not valid

Phoodbox address additional: Phoodbox address additional is not valid

Phoodbox address residance: Phoodbox address residance is not valid

Phoodbox delivery date: Phoodbox delivery date is not valid

Address additional: Address additional is not valid

Recurring payment enable: Recurring payment enable is not valid

User Telefoon:* User Telefoon is Required

User Comment: User Comment is not valid

Email:* Invalid Email

Password:* Invalid Password

Password Confirmation:* Wachtwoordbevestiging komt niet overeen

Have a coupon?

Coupon Code:

Invalid Coupon

Stripe Payments

Pay with your Credit Card via Stripe Checkout

Javascript is disabled in your browser. You will not be able to complete your purchase until you either enable JavaScript in your browser, or switch to a browser that supports it.

Ik heb de gebruikersvoorwaarden en het privacy-beleid gelezen en ga hiermee akkoord.*

No val Please fix the errors above