This is an HTML version of an attachment to the Freedom of Information request 'Tender Documents: 532290 - Sunset Park Leachate Network Upgrade – Concept Design Consultancy'.


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 - $51.70 GST Exempt (from 10 August 2020)
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 Council.
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
Print
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CC11097 (4 Aug 2020) © Brisbane City Council - Corporate Forms