Fill - Free fillable Credit Card Authorization Form B70 1037 PF RE (City of Beaverton) PDF form

Form B70-1037 REV 8/15

City of Beaverton

Building Services

FAX: (503) 526-2550

Today’s Date:

Amount of Charge:

Job Address:

Card Number:

Expiration Date:

[ ] VISA, [ ] Discover, or [ ] MasterCard

(City of Beaverton does not accept American Express.)

Any amount over $2,000 is subject to a convenience fee equal to the transaction fee charged by the card issuer. A

separate convenience authorization form is required.

Name as Shown on Card:

Authorized Signature:

Print Name of Signer:

Phone Number:

IMPORTANT: City of Beaverton 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 Beaverton’s Building Division. Information

may not be shared with any other person (persons) or entity (entities) other than for fees associated with permit issuance for which

the transaction is intended. Because this information is confidential, this form will be shredded upon completion of processing fees.

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 AUTHORIZATION FORM

Beaverton’s Building Division’s FAX: (503) 526-2550

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Credit Card Authorization Form B70 1037 PF RE (City of Beaverton)

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Fill Online, Printable, Fillable, Blank Credit Card Authorization Form B70 1037 PF RE (City of Beaverton) Form