This is an HTML version of an attachment to the Freedom of Information request 'TITLE: First Local Housing Strategy REPORT'.

Credit Card Authorisation
This form is to be completed by the card holder, or designated officer of the City if received over the phone.
Card Holder Authorisation
I hereby authorise the City of Joondalup to debit the credit card identified below.
For the amount of
$
(total amount due)
I acknowledge that a declined payment may instigate collection proceedings by the City of Joondalup.
Purpose of Payment
Property Number (if applicable):
Personal Details
Name:
Address:
Billing Address: (if different from above)
Phone:
Signed: (to be signed by a City of Joondalup Officer if telephone authorisation)
Cardholder Signature:
City of Joondalup Officer Signature:
Date:
Credit Card Information
Credit Card Number: 



Expiry Date:                                   Card Security Number:        Credit Card Type:
/
 Visa    Mastercard
Name on Card:
Signature:                                                                                                                             (leave blank if received over the phone)
Office Use Only
Received by:
Authorised by:
Signature:
Date:                      
Invoice Number: (if applicable)
City of Joondalup  Boas Avenue Joondalup WA 6027  PO Box 21 Joondalup WA 6919  T: 9400 4000  F: 9300 1383  www.joondalup.wa.gov.au
LAST UPDATED AUGUST 2011