Credit Card Authorization Form

in Forms

Please fill out all the fields below. Once submitted, a staff member from our administration office will call you to retrieve the credit card number and expiry date.

Alternatively, you can fill out the PDF Credit Card Authorization Form and email or fax to us at 403-934-4889.

Name*
First Last
Company Name (if applicable)
Name
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email*
Enter Email Confirm Email
Purpose of purchase*
Card Type*
- Mastercard
- Visa
Authorized Charge*
File Upload
Attach an application or form that you wish to pay via credit card.
Drop files here or

Max. file size: 100 MB.
Consent*
I confirm I have the authority to charge this credit card and I authorize Wheatland County charge the amount shown above.
I agree
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Comments
This field is for validation purposes and should be left unchanged.

Credit Card Authorization Form

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