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Credit Card Authorization

  1. Credit Card Type*

  2. Name on Card

  3. Name as it appears on City of Goodlettsville Account

  4. Service Address

  5. By checking this box, I give authority to the City of Goodlettsville to draft my credit card account for the payment of my monthly utility bill. I understand this authority shall remain in full force and effect until written notification of termination is received from me or until the City of Goodlettsville has sent me ten (10) days written notice that they will end this agreement. I understand that nothing contained in this Authorization shall serve to reduce my obligation to pay my utility bill and services may be subject to delinquency fees and possible disconnection of service if the credit card transaction is declined for any reason. *

  6. Leave This Blank:

  7. This field is not part of the form submission.