CARD CONSENT FORM

Credit/Debit Card Processing- Consent

This consent form is for the Office of Denair Community Services to retain your card information on file forthe customer to CALL and make a payment OVER THE PHONE.

If you want to sign up for AUTO PAYMENT please fill out the AUTO PAYMENT FORM on the pay online page.

Customer Name (required)

Service Address (required)

Account Number (required)

Email (required)

Phone Number (required)

Renter or Owner (required)

If a renter please provide lease agreement. If not provided payment can not be made.

Name on Card

Card Number

Card Expiration Date

CVC Number

Billing Zip Code

I will call the Denair Community Services Office on the day I would like my card processed. (required)

I agree

I, the credit card holder, consent to Denair Community Services District retraining the credit card information it obtains when I make a payment to the District by credit card; any use of the credit card to pay for any services or to make any purchase can only be done with the advance, further consent by the card holder. Credit card information retained by Denair CSD will be used only for payments to be made to the district, that the card holder has specifically consented to. Denair CSD will not disclose the card information or any information concerning the card holder to any third person, unless required by law. (required)

I agree

Convenience fee will be applied to payment by credit card processing company (Fees verify based off card type and amount) (required)

I agree

By typing my name below, I understand and agree that this form of electronic signature is the same as a manual signature (required)

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If you do not want to send your card information thru this form please call the office at 209-634-4986 or visit us in person at 3850 N Gratton Road Deniar CA 95316.

Credit/Debit Card Processing- Consent

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