BRISBANE CITY COUNCIL   ABN 72 002 765 795
Instructions
Credit Card Authorisation
Return completed form to:
Right to Information Unit
Right to Information
via e-mail to: xxxxxxxx.xxx@xxxxxxxx.xxx.xxx.xx
or post to: GPO Box 1434 Brisbane Q 4001
Privacy Statement 
The personal information collected on this form will be used by Brisbane City Council for the purposes of 
fulfilling your request and undertaking associated Council functions and services. Your personal information 
will not be disclosed to any third party without your consent, unless this is required or permitted by law.
APPLICANT DETAILS
Full name
Date
/            /
Postal Address (a receipt will be posted to this address)
Suburb
State
Postcode
Phone number
Mobile phone number
E-mail
(           )
FEES AND CHARGES
Application fee - $55.75 GST Exempt (from 1 July 2024)
Processing/access charges (an invoice will be sent) 
Amount $
CONFIDENTIAL 
CREDIT CARD DETAILS and AUTHORISATION
I hereby authorise Brisbane City Council to debit my credit card for the amount below as payment for products and services provided 
by Council.
For credit and debit card payments, a surcharge may apply. For more information about payment surcharges, visit brisbane.qld.gov.au 
and search ‘credit and debit card surcharge’. 
Payment:
MasterCard
VISA
Complete only the first four (4) and last four 
Card number
(4) digits of the card number. You will be
phoned by a Brisbane City Council Officer to
obtain the remaining credit card numbers.
Expiry date
/
Amount
$
Name
Signature
Print
Reset
CC11097 (24 June 2024) © Brisbane City Council - Corporate Forms

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