BRISBANE CITY COUNCIL ABN 72 002 765 795
Credit Card Authorisation
Instructions
Return completed form to:
Right to Information Unit
Right to Information
via e-mail to: xxxxxxxx.xxx@xxxxxxxx.xxx.xxx.xx
or fax to: 3330 0043
or post to: GPO Box 1434 Brisbane Q 4001
Privacy Statement
The personal information collected on this form will be used by Brisbane City Council for the purposes of
fulfilling your request and undertaking associated Council functions and services. Your personal information
will not be disclosed to any third party without your consent, unless this is required or permitted by law.
APPLICANT DETAILS
Full name
Date
/ /
Postal Address
(a receipt will be posted to this address)
Suburb
State
Postcode
Phone number
Mobile phone number
Fax number
(if applicable)
( )
( )
E-mail
FEES AND CHARGES
Application fee - $49.70 GST Exempt (from 1 July 2018)
Processing/access charges (an invoice will be sent)
Amount $
CONFIDENTIAL
CREDIT CARD DETAILS and AUTHORISATION
I hereby authorise Brisbane City Council to debit my credit card for the amount below as payment for products and services provided
by Compliance and Regulatory Services.
Payment:
MasterCard
VISA
Complete only the first four (4) and last four
Card number
(4) digits of the card number. You will be
phoned by a Brisbane City Council Officer to
obtain the remaining credit card numbers.
Expiry date
/
Amount
$
Name
Signature
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CC11097 (15 June 2018) © Brisbane City Council - Corporate Forms