Fillable CREDIT CARD AUTHORIZATION FORM (City of Oxnard)

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CREDIT CARD AUTHORIZATION FORM (City of Oxnard)

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The CREDIT CARD AUTHORIZATION FORM (City of Oxnard) form is 1 page long and contains:

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  • 2 check-boxes
  • 16 other fields

Country of origin: US
File type: PDF

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C:\Users\dee.lai\Desktop\Dee\!Forms & Labels\Forms & Logs\Credit Card Authorization Planning.doc
CREDIT CARD AUTHORIZATION FORM
C A R D H O L D E R I N F O R M A T I O N
Name On Credit Card
Card Holder Billing Address
City
State
Zip Code
Contact Person
Title
Phone No.
Credit Card Number
CVV2 or CID No. (3 digit No.)***
Expiration Date
Card Type
Visa
Mastercard
Amount
P L A N N I N G I N F O R M A T I O N
Zone Clearance Home Occupation Permit TUP
Other:
PZ No.:
Business
Residence Other
Address:
*** Card Identification Number (CID No.) is the last three (3) digits located on the back of the credit card.
By signing below I, being the cardholder or authorized user, agree to pay the amount of
$____________ (Initial_______) and specifically authorize the City of Oxnard to charge my credit
card in that amount.
Please be sure to initial the amount authorized and sign below.
_________________________________________________________________________
Printed Name Signature of Card Holder Date
_________________________________________________________________________
Received By Department Ext Date
Date:
# Pages:
To:
From:
Co./Dept.: Planning
Co.
Phone #:
Phone #:
Fax #: (805) 385-7417
Fax #:
FOR OFFICE USE ONLY
Form of Acceptance: EM ZM AM NM
Approval #:___________________________________
Receipt#____________________________
(GIVE TO CUSTOMER)
Clerk Initial:______________ Date:________________
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CREDIT CARD AUTHORIZATION FORM (City of Oxnard)

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Completed 31 January 2021

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