Use this form to have your monthly CPW bill automatically charged to your Visa or MasterCard every month.

Print & Complete the Credit Card Payment Plan Authorization form below Fax the completed form to 864-984-5356 or mail to: Laurens Commission of Public Works P.O. Box 349 Laurens, SC 29360

Credit Card Payment Plan Authorization

I authorize the Laurens Commission of Public Works to charge my bill payments to my credit card account each month. I understand that if at any time I decide to discontinue this payment service I will notify the Laurens Commission of Public Works. The Credit Card Payment Plan is a free service provided by the Laurens Commission of Public Works.

Signed:
Date:

Customer Information

Name
Service address
Street
City
State
Zip Code
Mailing address (if different from above)
Street
City
State
Zip Code
Telephone (daytime)
(evening)
LCPW Account Number

Credit Card Information

Type of credit card to be used (Please circle one.)
	VisaMasterCard
Name on card
Card Number
Expiration