Fillable PRINT AND COMPLETE AUTHORIZATION AND RETURN (City of Midland Texas)

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PRINT AND COMPLETE AUTHORIZATION AND RETURN (City of Midland Texas)

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File type: PDF

U.S.A. forms for City of Midland Texas

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Name on Card
Billing Address
Card Type
Visa Mastercard
Card Number: / / /
Experation Date:
/ /
Identification Number:
Authorized Amount to Charge:
I authorize the CITY OF MIDLAND to charge the amount listed above to the card provided
herein. I agree to pay for the purchase in accordance with the issuing bank cardholder
Cardholder--Please Sign and Date
Signature
Date
Printed Name
Project Name
Plan#
Dalia Salinas-Admin Clerk
Invoice#
City of Midland
300 N. Loraine
Midland, TX 79701
432-685-7400
dsalinas@midlandtexas.gov
Authorization for Credit Card Use
PRINT AND COMPLETE AUTHORIZATION AND RETURN
All Information will remain confidential
Please Submit form to:
Zip Code:
$_______________________________
***Office Use***
(Needed to Process Payment)
(3 digits on back of card)
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PRINT AND COMPLETE AUTHORIZATION AND RETURN (City of Midland Texas)

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Completed 23 January 2021

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