HomeMy WebLinkAboutAuthorization Form for Credit Card PaymentBUILDING & CODE REGULATION DIVISION
2300 VIRGINIA AVENUE
FORT PIERCE, FL 34982
;[ :L�•Lt �YL-max 772-462-1553
FAX 772-462-1578
AUTHORIZATION FORM FOR CREDIT CARD PAYMENT
TO: St Lucie County
13M
Permit # aUo(-Q 6� 1
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 pro essed the following business day.
VISA MASTERCARD A � r�\K
Credit Card Number _� a1 'Doo a 008
Expiration Date Zip Code 3cj9 5?�
3 digit security code 3 4 (o
Amount $ :� ( • II 3 + 1.5% surcharge
Business Name:
Authorized Signature•
Print Name: Gib ecc c� M.as ,
Phone: (117)
Fax: ( )
Comments:
SLCPDSD Revised 4/0112010 EN