Public Works Department
1813 Reliance Pkwy
Bedford, TX 76021
Ph: (817) 952-2200 Fax: (817) 952-2240
Instructions for Completing the Credit Card Payment Form
• Enter all credit card information including the payment amount to be charged to your credit card and remember to sign the
form. The City of Bedford cannot process an incomplete form or process credit card payments without an authorized
• The City of Bedford does not accept debit cards or check cards that require use of a personal identification number as a
method of payment.
• Address information is required for credit card payment as a means of verification. Failure to complete the address
information may result in the payment not being accepted by your credit card institution.
• The City of Bedford requires using this form for credit card payments submitted by mail, facsimile, or email. To protect your
credit card information, use only this form.
• Credit Card Information must include the 3 digit security code on the back of the credit card: example:
• If the cardholder includes a credit card number on any form or document other than the Credit Card Payment Form or
submits this form electronically via fax or email, the City of Bedford will not be liable in the event that the credit card
number becomes public knowledge.
• This PDF file contains form fields allowing you to type in your pertinent information. Once filled out, it can be printed out
and faxed to 817-952-2240, scanned and emailed to
email@example.com or mailed to City of Bedford, Attn:
Public Works Permits Processing, 1813 Reliance Pkwy, Bedford TX 76021. Please note for additional security purposes this
PDF file will not allow a filled out form to be saved, only printed.
Credit Card Type: Visa MasterCard
Credit Card Account #:
(on back of card)
Name as it Appears on Card
Credit Card Billing Address
Street Address 2:
Describe Purpose of Payment:
I authorize The City of Bedford to keep this information on file for future use.
I do not authorize The City of Bedford to keep this information on file for future use. Please use for the current transaction
I authorize The City of Bedford to charge my credit card account for payment of permits, inspections, contractor registration or
any associated fees with the City of Bedford and to verify the billing address of my Credit Card with the issuing bank upon my
signature. If The City of Bedford is unable to process my payment, I will be responsible for an alternate payment arrangement
and any penalty fee which results. By signing this authorization, I acknowledge that I have read and agree to all of the above.
All information given is complete and accurate.
Card Holders (signature):