Credit Card Payment Authorisation


             Add: 48 Longueville Rd, Lane Cove  Post: PO Box 20 Lane Cove 1595  Lane Cove
             Tel: (02) 9911 3555  Fax: (02) 9911 3600 Web: lanecove.nsw.gov.au Eml: xxxxxxxxx@xxxxxxxx.xxx.xxx.xx

Introduction
This form can be used for providing payment by credit card for Council services. Please
attach this form to the front of any relevant documentation to ensure fast processing of
your payment.
Payment
Please charge my credit card for payment of:-
Details
LEP Amendment Application
 Property Rates (please specify customer reference no.) .............................................
 Resident Parking Permit                  Tree Pruning/Removal Application
 Zoning (s149) Certificate                 Outstanding Rates (s603) Certificate
 Documents or Other (please specify:  .........................................................................

Payment

A 1% service fee (incl.GST) applies to all credit card
$
Amount

Payments.
Cardholder
Name on Card:................................................................................................................
Details
Address:..........................................................................................................................
Suburb:  ................................................................ Postcode:  .........................................
Phone Numbers: .............................................................................................................
Card Details
 MasterCard                                   VISA
(We DO NOT
accept Amex
Card No:    
or Diners
Club Cards)
Expiry date: /

Signature of Cardholder ....................................................  Date ....................................
* Please note that this payment is subject to approval of funds by your financial institution.
Council
Lane Cove Council Customer Service Centre
Details
48 Longueville Road, Lane Cove NSW  -  PO Box 20 Lane Cove NSW 1595
www.lanecove.nsw.gov.au - E-mail: xxxxxxxxx@xxxxxxxx.xxx.xxx.xx
Phone: 02 9911 3555 Fax: 02 9911 3600
Your Privacy
The personal information you have supplied on this form is required to assist Council officers when determining
your application.  Failure to provide some details may result in rejection or delays.  The details provided are not
publicly available.  At anytime you have access to view or correct any information you have supplied.  The
information you have supplied will be stored at Council offices.
By Phone?
Initial:
Date:
Office Use

Ref No:
Receipt No:
Date:

Trim No: 15943/05

Document Outline