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:
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Permit
Credit Card Users: 1.5010 Sunchaige 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% VISA \ MASTERCARD
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Credit Card Number# N,
Expiration Date MR,., : •.r, a;) Zip Code
3 digit security code i^n'T/
Amount !(9 • :, v. + 1.5% surcharge
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Business Name:
Authorized Signa
Print Name: 6r`7. ,ui„ Mr:;;; 77
Phone: s�
Fax: r_ , ,
Comments:
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SLCPDSD Revised 4/01/2010 EN