HomeMy WebLinkAboutAuthorization Form for Credit Card PaymrntBUILDING & 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:[%�
Permit#C
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.
("— VISA
Credit Card Number
Expiration Date i —
3 digit security code
Amount
Business Name:
Authorized Signa
E�Y-IMASTERCARD
Zip Code
+ 1.5% surcharge
Print Name:
Phone: G�3� )C_:12
Fax:
1 . u�TT'1iLliizil
SLCPDSD Revised 4/0112010 EN