Fillable Form 4: FORM CREDIT CARD AUTHORIZATION (City of Marco Island Florida)

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Form 4: FORM CREDIT CARD AUTHORIZATION (City of Marco Island Florida)

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Credit Card Authorization Form/F:Samantha/Community Coordinator/Forms 10/16/2013 Page 1 of 1
smalloy@cityofmarcoisland.com
*Please complete this authorization form and return to us. All information will remain confidential.
Name as it Appears on the Card:
Billing Address:
We only accept Visa and Mastercard
Credit Card Type: Visa Mastercard
Credit Card Number:
Expiration Date:
Card Identification Number (last 3 digits located on the back of the card):_______________
Amount to Charge: $
Reason for Charge:
Authorization Agreement:
I authorize the City of Marco Island Parks and Recreation Department, to charge the agreed
amount listed above to my credit card provided herein. I hereby represent that I have the
authority to execute this credit card authorization and agree that this Authorization will be
effective on the date signed below. I understand and consent to the use of my credit card
without my signature on the charge slip, that a photocopy or fax of this agreement will serve
as an original, and this Credit Card Authorization cannot be revoked.
Signature of Cardholder Date
City of Marco Island
Parks and Recreation Department
1361 Andalusia Terrace
Marco Island, FL 34145
Ph
o
n
e:
2
39
-
6
42-
0575
o
r
FAX
:
2
39
-
6
42-
6
4
75
CREDIT CARD AUTHORIZATION
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Form 4: FORM CREDIT CARD AUTHORIZATION (City of Marco Island Florida)

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Completed 10 June 2021

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