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