Fillable 1637 Credit Card Authorization Form (City of Beaverton)

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1637 Credit Card Authorization Form (City of Beaverton)

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The 1637 Credit Card Authorization Form (City of Beaverton) form is 1 page long and contains:

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File type: PDF

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Form B70-1037 REV 8/15
City of Beaverton
Building Services
FAX: (503) 526-2550
Today’s Date:
Amount of Charge:
Job Address:
Card Number:
Expiration Date:
[ ] VISA, [ ] Discover, or [ ] MasterCard
(City of Beaverton does not accept American Express.)
Any amount over $2,000 is subject to a convenience fee equal to the transaction fee charged by the card issuer. A
separate convenience authorization form is required.
Name as Shown on Card:
Authorized Signature:
Print Name of Signer:
Phone Number:
IMPORTANT: City of Beaverton respects your privacy. Information provided on this form is confidential and used solely for the
purpose of completing credit card transactions for business associated with the City of Beaverton’s Building Division. Information
may not be shared with any other person (persons) or entity (entities) other than for fees associated with permit issuance for which
the transaction is intended. Because this information is confidential, this form will be shredded upon completion of processing fees.
CITY OF BEAVERTON
Community Development Department
Building Division
12725 SW Millikan Way / PO Box 4755
Beaverton, OR 97076
Phone: (503) 526-2493 Fax: (503) 526-2550
General Information (503) 526-2222 V/TDD
BeavertonOregon.gov
CREDIT CARD AUTHORIZATION FORM
Beaverton’s Building Division’s FAX: (503) 526-2550
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1637 Credit Card Authorization Form (City of Beaverton)

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Completed 2 August 2020

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