CREDIT CARD
AUTHORIZATION
PERMIT OFFICE
2220 FOURTH STREET P.O. BOX 32 ROSENBERG, TEXAS 77471-0032 832-595-3500 FAX 832-595-3501
Rev. 1.2.19-JL
CREDIT CARDHOLDER INFORMATION
NAME ON CREDIT CARD
TYPE OF CREDIT CARD (Check Appropriate Box)
VISA
TYPE OF ACCOUNT (Check Appropriate Box)
BUSINESS
COMPANY NAME
CREDIT CARD NUMBER
EXPIRATION DATE
*CCV/Security Code
BILLING ADDRESS
CITY
STATE
ZIP CODE
EMAIL
PHONE NUMBER
FAX NUMBER
AUTHORIZATION OF CARD USE
I certify that I am the authorized holder and signer of the credit card referenced above.
I certify that all information above is complete and accurate.
I hereby authorize collection of payment for all charges associated with the permit application submitted for:
______________________________________________ (Address AND Permit Number, if applicable)
Charges may not exceed the amount of the permit plus the 3% credit card fee charged for administrative purposes.
($_______________, if known at time of submission)
I understand this authorization form will be shredded once payment is approved and paid. Also, I understand each
time a permit application is submitted that a Credit Card Authorization will be attached for payment. A faxed copy
of the permit and receipt will be faxed back to the above referenced fax number.
CARDHOLDER NAME (Printed)
SIGNATURE
DATE