CITY OF HERMOSA BEACH
AUTHORIZATION FOR CREDIT CARD CHARGE

NAME:_______________________________________________________________

ADDRESS:____________________________________________________________

CITY, STATE, ZIPCODE: _________________________________________________

DAYTIME PHONE NUMBER: __(_______)___________________________________

MASTERCARD #:_____________________________________________

VISA CARD #:________________________________________________

CARD EXPIRATION DATE:_____________________________________

Last 3 digits of the number on the signature strip located on the
backside of the card: ____________.

     I authorize the City of Hermosa Beach to charge these services
     to the credit card listed above:

________________________________________________________________
    CARDHOLDER SIGNATURE DATE

 

    FAX FORM TO: (310) 937-5959, ATTENTION: FINANCE

    OR MAIL TO:

CITY OF HERMOSA BEACH
FINANCE DEPARTMENT
1315 VALLEY DRIVE
HERMOSA BEACH, CA. 90254
(310) 318-0217