Authorisation for 
Credit Card Payment 
Print Form
You can type into this 
form before printing
to Eurobodalla Shire Council
If you need help: 
Office use only
Send your form to: 
  
The General Manager 
Officer
Phone us on  
Eurobodalla Shire Council 
(02) 4474 1000 
PO Box 99 Moruya 2537 
Receipted amt $
  
(DX 4873 Moruya) 
Or  
xxxxxxx@xxx.xxx.xxx.xx 
Received date
Come in and see us at: 
  
89 Vulcan St Moruya NSW
Or bring it to: 
Receipt No.
Customer service office 
Receipt to (code)
89 Vulcan St Moruya NSW
 Customer details
Mr
Mrs
Ms
Dr
Other
Your Reference:
It is important that  Business/ company name
we can contact 
you if we need 
Contact name(s) 
more information 
or if there is a 
problem with 
Postal address
your payment. 
Please give as 
Daytime phone
Mobile
much detail as 
possible. 
Email address
Send copy of receipt by
Email
Post
Receipt not required
 Payment details
Describe what this 
payment is for, so 
we can correctly 
allocate your 
payment.  
What is this  
payment for? 
Please include any   
relevant reference 
numbers  (e.g. 
application 
number)
 Credit Card Details 
Please note a 1% merchant charge applies when paying by credit card
Please debit my:
Mastercard
Visa Card
[other card types are not accepted at this time]
Enter Payment Amount:
+ 1% Merchant Charge
Total Payment
 Credit card number:
/
/
/
Card expiry date:
CVV (3 digits):
Cardholder's Name:
Cardholder's Signature:

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