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

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    Lionel Boopathi
    49 views1 page
    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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    Credit-Card-Payment-Form

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    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.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pdf or txt
    49 views1 page

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

    Uploaded by

    Lionel Boopathi
    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.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pdf or txt
    of 1

    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
    ccchazmat@cchealth.org
    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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