FINANCIAL SERVICES
Fax to: (02) 4645 4472
Authorisation Form - Credit Card Payments
Privacy Statement
The information requested by Council on this form may constitute personal information under the
Privacy and Personal
Information Protection Act 1998. Council is allowed to collect the information from you to consider this matter. Supplying this
information is voluntary. However if you cannot or do not wish to provide the information, we may not be able to consider the
matter. If you need further details, please contact the Privacy Officer, Campbelltown City Council, cnr Queen and Broughton
Streets, Campbelltown.
Please charge my credit card for the following services:
MASTERCARD
VISACARD
Credit Card No.
___ ___ ___ ___ / ___ ___ ___ ___ / ___ ___ ___ ___ / ___ ___ ___ ___
Amount $ ___________________
All credit card payments will incur a Merchant Service Fee
surcharge of 0.60%.
Card Expiry Date
___ ___ / ___ ___
Cardholder's Name
Cardholder's Signature
Contact Phone Number
OFFICE USE ONLY
Internal Reference Code:
Description:
Fax completed form to (02) 4645 4472 (Forms will not be accepted by email)
DATA AND DOCUMENT CONTROL
Financial Services
Revised Date: 04/08/2016
Page 1
DocSet: 1509099
Review Date: 30/09/2018
Version: 8