HomeMy WebLinkAboutAuthorization Form for Credit Card paymentN BUILDING &CODE REGULATION DIVISION
- J 2300 VIRGINIA AVENUE'
. `�,, FORT PIERCE, FL 34982
772-462-1553
- FAX 772-462-IS78
AUTHORIZATION FORM FOR CREDIT CARD PAYMENT
T0: St Lucie County
RE:
Permit #
Credit Card Users: 1,501c, Surcharge added per transaction.
Payments must be received in th's 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 Zy 1.S4j J i
Expiration Date 12 /.2 Zip Code __3�� Q T
3 digit security code f 0 '
Amount $ + 1.5% surcharge
Business Nan
Authorized Si
Print Name:
Phone:
Fax:
SLCPDSD Revised 4/01/2010 EN