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)