City of Cedar Hills Utah

Payment Form for Special Event

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Organization or Event Name

Start Date of Event

Pay with Xpress Bill Pay

	Special Event Fee	100.00
Subtotal

Card Holder Name *

Credit Card Number *

Security Code *

Exp Month *

Exp Year *

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I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.