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BUILDING & CODE REGULATION DMSION
2300 VIRGINIA AVENUE
FORT PIERCE, FL 34982
772-462-1553
FAX 772-462-1578
AUTHORIZATION FORM FOR CREDIT CARD PAYMENT
TO: St Lucie County
UA
Permit#
Credit Card Users: 1,5% Surcharge added per bansaction.
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 MASTERCARD
Credit Card Number `L I 6 4 d 6la s 40$ 01-O f
Expiration Date Z/ 23 Zip Code
3 digit security code ZL4
Amount $ + 1.5% surcharge I Q
Business Name:
Authorized Signature:
Print Name:
Phone: Rf,
Fax:
Comments:
SLCPDSD Revised 4/01/2010 EN