HomeMy WebLinkAboutSt. Lucie County Credit Card Authorization (1)
BUILDING & 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: ____________________________
Permit # _________________________
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 processed the following business day.
_____ VISA _____ MASTERCARD
Credit Card Number _____________________________________
Expiration Date ___________________ Zip Code _____________
3 digit security code ________________
Amount $___________________ + 1.5% surcharge
Business Name: __________________________________________________
Authorized Signature: _____________________________________________
Print Name: _____________________________________________________
Phone: (_____) ________- ___________
Fax: (_____) ________- ___________
Comments:
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
SLCPDSD Revised 4/01/2010 EN