HomeMy WebLinkAboutAnderson C.C. AuthBUILDING & CODE REGULATION DIVISION
J 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: .56 - S,g t/9NN/)N Jr
Permit #
Credit Card Users: Z,S% 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
MASTERCARD
Credit Card Number yVz /3V 757a �S3y
Expiration Date _ /o / 2,2 Zip Code 3lif r
3 digit security code S"6v
Amount $ � .oho surcharge
Business Name:
Authorized Signature:
Print Name: 4✓»qF• n ,..•
Phone:
Fax: ( )
Comments:
SLCPDSD Revised 4/01/2010 EN