Credit Card Payment Form printable pdf download

Credit Card Payment Form

CREDIT CARD PAYMENT FORM

Date ______________

Please deduct from my credit card

$_______________

Being payment for __________________________________________

Account Number ___________________

CREDIT CARD DETAILS:

Cardholders Name ________________________________________

Expiry Date

Card Number

Card Type

Bank Card

MasterCard

Visa Card

Credit Card Signature _____________________________

CONTACT DETAILS:

Name _________________________________

Address ___________________________________

Postcode _______

Phone (Daytime) _____________________

(Mobile) ____________________

TERMS & CONDITIONS:

•

You agree that all of the information you have produced to the City of Cockburn in relation to the credit card

payment is correct.

•

You warrant City of Cockburn that you are fully authorised to use the credit card details as provided on the

form.

•

You warrant to the City of Cockburn that your credit card is within validity date and is not listed on any warning

bulletin held by any bank or credit card provider.

•

Whilst the City of Cockburn will use all reasonable endeavours to ensure the security of your information

provided, the City of Cockburn does not warrant that other parties will not assess the information.

Credit Card Payment Form