HomeMy WebLinkAboutAuthorization Form for Credit Card PaymentArt"I BUILDING & CODE REGULATION DIVISION
S'. d 2300•VIRGINIAAVENUE
p FORT PIERCE, FL 34982
• l 772-462-1553
FAX 772-462-1578
AUTHORIZATION FORM FOR CREDIT CARD PAYMENT
TO: St: Lucie County
RE:
Permit ifi J M e74— 0Z;Z �3_
Credit Card Users: 1.5010 Surcharge added per transaction,
Payments must be received in this department by 4:00 PM for transaction to be
processed that day, if not it will be processed the following business day,
4 VISA MASTERCARD
Credit Card Number Y�O;Z-47 '5rl 91157
Expiration Date 2Z Zip Code
3 digit security code
Amount. $ + 1.5% surcharge
Business Nar
Authorized S
Print Name:
Phone:�—
Fax:
Comments: