Authority to Charge CREDIT CARD by lindahy

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Authority to Charge CREDIT CARD

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									                                      Authority to Charge CREDIT CARD




I, ……………………………………….. The undersigned, authorise the

Byron Shire Council to charge amounts indicated to the following credit card:



Amount:                       $…………………………


Payment For: ………………………………………………………………………………

                    ………………………………………………………………………………

                    ………………………………………………………………………………

                    *If applicable, please state application number(s).


 CONTACT NAME:

 ADDRESS:


 PHONE:                                           MOBILE:                              FAX:

PAYMENT SLIP


I wish to pay by                          MASTERCARD                         VISA

                                                                          Expiry date_____/_____


Card
Number
I authorize a credit card fee of 0.53% to be added to the above amount.




                                                                                            /      /
CARDHOLDERS NAME                           SIGNATURE                                        DATE




                                                                                                Doc #837788

								
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