Fillable Credit Card Authorization Form (City of Fremont)

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Credit Card Authorization Form (City of Fremont)

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RD_CCardAF/ec – Revised 09/2018
Charge Card Authorization
Credit Card Authorization for business tax registration and payments
Date: ____________________________
Business Name: _____________________________________________________________________
• • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •
Please forward business registration receipt to: (optional)
Attention: __________________________________________________________________________
Business Name: _____________________________________________________________________
Address: ___________________________________________________________________________
City: ____________________________________ State: _____________ Zip: ______________
Telephone: __________________________________ Fax: ________________________________
e-mail address: _____________________________________________________________________
• • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •
Print Name _______________________________________ Amount to be charged: $____________
(as it appears on credit card)
Authorized Signature: ______________________________________ Date: ___________________
• • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •
Please charge my (check one): Visa Master Card Amount to be charged: $____________
Card # ___ ___ ___ ___ – ___ ___ ___ ___ – ___ ___ ___ ___ – ___ ___ ___ ___ exp. ____ / ____
V–Code (3 digit): __________________ Billing Zip Code: _______________________
Finance Department | Revenue Division
39550 Liberty Street, Fremont, CA 94538
Ph: 510-494-4790 | Fax: 510-494-4754
www.fremont.gov
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Credit Card Authorization Form (City of Fremont)

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Completed 18 July 2020

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