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Payments Can Be Made Using Visa, Mastercard and Discover: Credit Card Payment Form

This document provides a credit card payment form for hazardous materials programs. It includes fields to enter credit card information like the card type, number, expiration date, security code, billing address and payment amount. The form notes a $15 minimum charge for credit card payments and includes spaces for office use to record details of the processed payment like facility IDs and the processing agent.

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Lionel Boopathi
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© © All Rights Reserved
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132 views

Payments Can Be Made Using Visa, Mastercard and Discover: Credit Card Payment Form

This document provides a credit card payment form for hazardous materials programs. It includes fields to enter credit card information like the card type, number, expiration date, security code, billing address and payment amount. The form notes a $15 minimum charge for credit card payments and includes spaces for office use to record details of the processed payment like facility IDs and the processing agent.

Uploaded by

Lionel Boopathi
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Anna M.

Roth, RN, MS, MPH


Health Services Director
Contra Costa
Randall L. Sawyer Hazardous
Deputy Health Director
Materials Programs
Matthew S. Kaufmann
4585 Pacheco Boulevard, Suite 100
Director of Hazardous Materials Programs Martinez, California 94553
Ph (925) 655-3200
Fax (925) 646-2073
[email protected]
www.cchealth.org/hazmat/
CREDIT CARD PAYMENT FORM

Payments can be made using Visa, Mastercard and Discover

Card Type: □ Business Card □ Personal Card

Business Name on Card:

Name on Card:

Payor Address:

Card Number: Expiration Date


Mo: Yr:

Security Code (CVV): Phone Number: Payment Amount:

Email Address (optional):

Signature of Cardholder Date

*NOTE: $15 MINIMUM CHARGE FOR CREDIT CARD PAYMENTS

For Office Use Only:


Facility ID (FA): Account (AR):

CUPA Facility ID: Processed by:

Revised November 2020

• Contra Costa Behavioral Health Services • Contra Costa Emergency Medical Services • Contra Costa Environmental Health & Hazardous Materials Programs •
• Contra Costa Health, Housing & Homeless Services • Contra Costa Health Plan • Contra Costa Public Health • Contra Costa Regional Medical Center & Health Centers •

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