Fillable Credit Card Authorization (City of Azusa)

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Credit Card Authorization (City of Azusa)

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

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Country of origin: US
File type: PDF

U.S.A. forms for City of Azusa

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Credit Card Authorization
TO: FROM:
FAX #: PHONE #:
REFERENCE NUMBER:
DESCRIPTION:
AMOUNT DUE: $
INSTRUCTIONS:
1)
Complete the entire remittance form below.
2)
Place Drivers License in box to the right.
3)
Scan and email to pflores@ci.azusa.ca.us
Place Driver’s License here and
photo copy this entire sheet.
CARDHOLDER NAME: ____________________________________________________
PLEASE PRINT
CARDHOLDER SIGNATURE: ________________________________________________
CARD BILLING ADDRESS: _______________________________ ZIP CODE: ________
□ VISA □ MASTER CARD EXPIRATION DATE: _______________________
CARD NUMBER: _________________________________ ZIP CODE: _______________
SECURITY CODE (From rear of card): ________ AMOUNT: $_____________
ACCEPT VISA OR MASTERCARD ONLY
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Credit Card Authorization (City of Azusa)

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Completed 15 January 2021

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