Today's Date:
Your Name:
Address:
Contact Number:
Email :
At my request, I herby authorize Town of Bancroft to charge the following to my Credit Card:
Property Tax Roll Number: Amount:
Utility Account Number: Amount:
Other: Amount:
Please note that we are unable to accept American Express as a method of payment at this time.
Credit Card Number: Exipry: CVV: (3 digit code on the back of Card)
Cardholder's Name:
I authorize the Town of Bancroft to charge the credit card indicated in this authorization from. This payment authorization is for the goods/services described above, for the amount indicated above only, and is valid for one time use only. I certify that I am the authorizaed user of this credit card.