HomeMy WebLinkAboutAuthorization Form for Credit Card PaymentBUILDING & CODE REGULATION DIVISION
2300 VIRGINIA AVENUE
FORT PIERCE, FL 34982
772-462-1553
FAX 772-462-1578
AUTHORIZATION FORM FOR CREDIT CARD PAYMENT
TO: St Lucie County
RE: ft i✓lsw T cm iRl' u'
Permit # �r��,:'
Credit Card Users: 1,5% 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.
;,I ' ei _' VISA {nr = MASTERCARD
Credit Card Numbenil" ?" !. s , ^ = '�-_ i5
Expiration Dated Zip Code
3 digit security coded! "-
Amount 1.5% surcharge
Business Name:
Authorized Signature:;,'
Print Name:i'� 41' h14 ��i"?+a s• a t ' "r Uv!zn t^
Phone:
Fax:
Comments:
SLCPDSD Revised 4/01/2010 EN