City of Madison Building Department
100 Hughes Road
Madison, AL 35758
Authorization for Automatic Credit Card Transactions
Cardholder’s Name: Driver’s License #:
Company Name or DBA:
City of Madison Business License Number:
Company Daytime Contact Number:
Fax number or e-mail address to return permits to:
Card Number: Visa or MasterCard?
Expiration Date (MMYY): Verification Code:
Billing Address (with zip):
The undersigned hereby authorizes the following person or person’s to use the credit card
identified herein via phone and fax for the purpose of purchasing building related permits on
behalf of the contractor/company/organization.
Person’s authorized to use credit card via phone or
fax (Please Print)
1. Driver’s License Number:
2. Driver’s License Number:
3. Driver’s License Number:
The City of Madison Building Department will secure this document and protect all information
contained herein. We will require certain pertinent information when someone calls in and requests a
permit via the phone. All permit applications must be completed and faxed/e-mailed to us. Our email
address is and the fax number is 256-772-5601. Once documents are faxed
or e-mailed to us, you must call 256-772-5644 to schedule inspections or online at
Signature of Cardholder: Date:
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