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
Permit # 200(0 -Og9,5
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.
VISA V MASTERCARD
Credit Card Number 5290 9900 //97 'Z'525
Expiration Date D 1-2V Zip Code 311951
3 digit security code 6,W&
Amount $ /00. °n + 1.5% surcharge
Business Name:
Authorized Signature:
Phone: (2L) 323 - R 7 S 5 1 al • 5cS
Fax:
Comments:
SLCPDSD Revised 4/01/2010 EN