HomeMy WebLinkAboutAuthorization Form for Credit 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:
Permit #
C5
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 IMASTERCARD
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and NumberfWa !11-50 - !, Y)
Expiration Date t Zip Code
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3 digit security code W7101COMM I _7 I JUW,.,) 5- Lk��
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Business Name:
Authorized Signature:
Print Name:
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Phone:
Fax:
Comments:
SLCPDSD Revised 4/01/2010 EN
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