Credit Card Payment Form printable pdf download

Credit Card Payment Form

STATE BAR OF TEXAS

Office of the Chief Disciplinary Counsel

CREDIT CARD PAYMENT FORM

(Please print legibly)

Name:_________________________________________________________________

Address:_______________________________________________________________

City:________________________ State:_____________________ Zip:____________

Telephone:__________________________ Facsimile:__________________________

Bar Number:______________ Email:________________________________________

TYPE OF REQUEST:

Rule Book

(01-1200-40400)

$20.00 X _____Quantity = $_________

Certificate of Good Standing

(01-1200-40240)

$25.00 X _____Quantity = $_________

Voluntary Resignation Certificate (01-1200-40240)

$25.00 X _____Quantity = $_________

Copy of Disciplinary Judgment

(01-1200-40250)

$15.00 X _____Quantity = $_________

Copy of Certified Judgment

(01-1200-40250)

$20.00 X_____ Quantity = $________

$_________TOTAL

Mail to:

Office of Chief Disciplinary Counsel

P.O. Box 12487

Austin, Texas 78711

Email:

Or fax to 512-427-4222

To pay by credit card: _____Visa ______MasterCard _____AMEX ______Discover

Account No. _______________________ Expiration Date: _______ Security Code: __________

Name on card (Please Print):_______________________________________________________

Signature: ______________________________________________________________________

Feel free to contact the Office of Chief Disciplinary Counsel if you have any questions.

P. O. BOX 12487, CAPITOL STATION, AUSTIN, TEXAS 78711, (512) 427-1350 OR 1-877-953-5535

08/14

Credit Card Payment Form