Fillable Authorizes Convenience Fee Charge for any amount over (City of Beaverton)

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Authorizes Convenience Fee Charge for any amount over (City of Beaverton)

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Authorizes Convenience Fee Charge for any amount over $2,000 based on the transaction fee
charged by the card issuer.
Today’s Date:________________________________________________________________
Amount of Charge:____________________________________________________________
Permit Number:_______________________________________________________________
[ ] VISA, [ ] DISCOVER, or [ ] MasterCard
(City of Beaverton does not accept American Express.)
Name Shown on Card:_________________________________________________________
Authorized Signature:__________________________________________________________
Print Name of Signer:__________________________________________________________
Phone Number:______________________________________________________________
City of Beaverton
Building Services
FAX: (503) 526-2550
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 CONVENIENCE FEE AUTHORIZATION FORM
IMPORTANT: DO NOT INCLUDE THE CREDIT CARD NUMBER. THIS FORM WILL BECOME A PUBLIC RECORD.
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Authorizes Convenience Fee Charge for any amount over (City of Beaverton)

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Completed 2 August 2020

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