credit card deduction authority€¦ · name / business name . address . town/suburb . contact...
Post on 14-Jun-2020
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Customer Authority Name / business name
Address
Town/Suburb
Contact phone number Mobile
Payment details: I/we authorise Bass Coast Shire Council to arrange for funds to be debited from my/our account.
The payment is for
Amount to be debited $ Please debit my: VISA Mastercard
Council Reference (if known)
Council holds all personal information in accordance with the Privacy and Data Protection Act 2014 (Vic).
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This section to be removed and destroyed by Council upon receipt of payment.
Card Number: Expiry Date:
Cardholders Name: __________________________________________
Authorised signature: _________________________________________ Date ___________
Credit Card Deduction Authority
Type of service eg. Planning Permit, Road Occupation Permit etc
(Please note Council does not accept Diners Club or AMEX)
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