HomeMy WebLinkAboutAuthorization Form Credit Card Payment11/20/2017 MON 10:22 FAX 5612432022
y i
2001/001
BUILDING & CODE REGULATION DIVISION
2300 VIRGINIA AWNUE
FORT PIERCE, FL 34982
772-462-1553
FAX 772-462-I578
AUTHORIZATION FORM FOR CREDIT CARD PAYMENT
TO: St Lucie County
RE:
Permit #(„'i,'ic,{
Credit Card Users: X.5010 Surcharge addedper #ransacitlon.
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.
I •
VISA i,,, MASTERCARD
(..rirvot r;;rri Ni
Expiration DateZip Code : r.'•-i��r,r
o
3 digit security codes.I.'
Amount 1.5% surcharge
Business Na
Authorized S
Print Name:
me: ., r•a r4 *'1 �:I �I, , • I+i.,ri tlii .e�I(:';d:`�Y�N;n 7A'n'�iI�111 J' a �I!•;rlliJ' i
Ignature: ;''s;l:.l;: ;pA';il.• >'Ii , ;,,, ,,,
Phone:,,"7
Fax: 7';, u6 ; ,h I .: ' �:' a,ti;l; ��; ;. j ' , 0
Comments:
it :rr9 j'9,5: yl ,rr.:Ill,ij'r�;�,'' 'a' w'r 'h'�•i x� II"14d 51 ,NW: �.ti r: n. ai• vl•'�,�,.u; '• ,'I,n'r '�R �t IIV'p'�•11 iP��� Lr,in�'y
°'��y, ,'� )1+ '1 � �'4 i ;•YI, �I;i;,.�;';,;!i �' i.,,l's:�"�;,ir'„v'. di.•;�Arv/P.rSi'd���63'.yi2..r�''
SLCPDSO Revised 4/01/2010 EN
0
3M4AA, cwn
COASTAL TESTING LABORATORY
P.O. BOX 2023
PALM CITY, FL 34991-2023
OFFICE 772 220-6688
FAX 772 287-1591
FAX COVER SHEET
SEND TO
i From
SAINT LUCIE COUNTY _•
Attention I Date U
BUILDING DEPT.
Office location" i Office location
Fax number, ! Phone number
Urgent RepfyASAA Please comment Please review ;" For your information
Total pages. including cover.
T00 lin T69TLSZZLL XVA ZE:6T LTOZ/6T/TT