City of Happy Valley
16000 SE Misty Drive, Happy Valley, OR 97086
Telephone (503) 783-3800 Fax (503) 658-5214
Webpage - www.happyvalleyor.gov
Credit Card Authorization Form
Today’s Date: ______________________________________________________
Amount of Charge: __________________________________________________
Job Site Address: ___________________________________________________
Permit Number: ____________________________________________________
Visa Master Card
Card Number:______________________________________________________
Expiration Date: (month/year) (07/2014) _________________________________
3 Digit Security Code (back side of credit card):____________________________
Billing Street Address: _______________________________________________
City, State, Zip: ____________________________________________________
Authorized Signature: _______________________________________________
Print Name of card holder: ____________________________________________
Phone Number: ____________________________________________________
Email Address: ____________________________________________________
This document will be shredded after your permit is processed.
Important: The City of Happy Valley 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 Happy Valley’s Building Department. Information may not be shared with
any other person (persons) or entity (entities) other than for fees for which the transaction is intended.
If you have any questions contact the Building Dept 503-783-3800.
Discover Card
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signature
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