Burn Permit Payment Form

COSubmission ID:

First Name:

Last Name:

Burn Address:

Year:

Payment Amount:

$

Billing Information

First Name:

Last Name:

Street Address:

City:

State:

Zip:

Phone:

Email:

Credit Card Information

Credit Card Number:

Expiration Date (MMYY):

Security Code:

By clicking “Submit” you authorize Frederick County Health Department to charge your payment card the amount entered above.