OFFICE USE ONLY
Date Received Time Received Received via Received By
_____/_____/_____ _____: _____ a.m./p.m. In person Mail Initials______
CREDIT CARD AUTHORIZATION FORM
Please use this form to authorize payment by credit card to the City of Coon Rapids
Send or fax this form to:
City of Coon Rapids
11155 Robinson Drive
Coon Rapids, MN 55433
The City of Coon Rapids will not be responsible for security when this form is faxed containing credit card information. For
your safety credit card numbers are not accepted via Email.
____Visa ____ Mastercard
*Account Number: ______________________________________________________________
*Expiration Date (month/year) ____ / ____ *CVC# ___ ___ ___ (back of card)
*Name on Card: _______________________________________________________________
*Billing Address: _______________________________________________________________
*City: ________________________________* State _________________ *Zip_______________
* Billing Phone Number __________________________________________________________
* Authorized Cardholder Signature _________________________________________________
All information requested is required to process your payment. Incomplete forms will not be processed.
TERMS OF ACCEPTANCE and SIGNATURE:
The applicant and/or submitter of this form, warrant the truthfulness of the information provided in this
document.
I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above
Terms of Acceptance as well as the terms of my credit card agreement.
Building Inspection - 763-767-6573 FAX
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