MIAMI-DADE COUNTY, FLORIDA DEPARTMENT OF PLANNING AND ZONING CERTIFICATE OF USE CREDIT CARD AUTHORIZATION FORM PHONE: (786) 315-2666 FAX: (786) 315-2928 Date: ______/______/______ Process Number: U ____________________________ List business name and address as applied for in the Certificate of Use (C.U.) application: !Business Address: _______________________________________________________ !Business Name: _______________________________________________________ Credit Card Type: Master Card ____ Visa ____ Credit Card Number: ______________________________ Expiration Date: ______/______ Amount Authorized to Charge: $ _____. ____ Actual Amount of Charge: $ _____. ____ Note: Actual amount charged must be the same or less than the amount authorized by the signer. Signature as it appears on the Credit Card (copy attached): Authorization Signature X _________________________________________________ Print Name: ________________________ Phone No.: ( ) _________ - _____________ Mailing Address ___________________________________________________________ City _______________________State__________ Zip Code ____________________ IMPORTANT: YOU MUST ATTACH A LEGIBLE COPY OF BOTH SIDES OF YOUR CREDIT CARD! American LegalNet, Inc. www.FormsWorkflow.com