CREDIT CARD AUTHORISATION
HOW TO COMPLETE THIS FORM
1. Complete all fields ensuring that all mandatory fields marked with * have been completed
2. Once completed submit this form to Inner West Council - Leichhardt Service Centre by either email to
xxxxxxxxxx@xxx.xxx.xxx.xx ; by post to PO Box 45 LEICHHARDT NSW 2040; or by fax to 9367 9111
3. Payment wil not be processed unless all information is present, including if other relevant forms/documentation
needs to be attached.
CUSTOMER DETAILS
Surname *
Given Name/s *
Company Name *
(if applicable)
Postal Address
Suburb
Postcode
Home Phone Number
Business Number
Mobile
Fax Number
Email address
Reason for Payment: If paying for multiple services, please itemise.
If you are paying an invoice please state the Debtor ID and Invoice Number
OFFICE USE ONLY
Application Number or details
Council Officer:
Date:
Receipt Number
Amount
$
CREDIT CARD DETAILS
Please note that an additional 0.8% merchant service fee wil apply to al payment made by credit card.
Cardholders Name * (Please print in capital letters)
Credit Card Details * (Visa and MasterCard only)
Visa
MasterCard
CVC * (3 digit reference on the back of credit card)
Credit Card Expiry Date *
/
AUTHORISATION
I hereby authorise Inner West Council to debit my credit card in the amount of: * $
(Please specify the amount)
Card Holders Signature *
Contact Telephone No. *
Date *
Is a receipt required? (Unless otherwise stated the receipt wil be made out to the cardholders name)
Inner West Council – Leichhardt
│
xxxxxxxxxx@xxx.xxx.xxx.xx
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Updated: June 2016
Credit Card Authorisation
│
PO BOX 45, Leichhardt NSW 2040
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