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Harris County Dba Form

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OFFICE OF STAN STANART

COUNTY CLERK, HARRIS COUNTY, TEXAS

INFORMATION AND PUBLIC SERVICE DEPARTMENT

FOR CUSTOMER USE ONLY (Please print or type)

Name of Cardholder:

Date:

Address:

City:

State:

Zip:

Phone No.:

Fax No.:

Email Address:

PLEASE PROVIDE REQUESTED PAYMENT INFORMATION

Credit Card: □ Visa

□ MasterCard □ Discover □ American Exp.

There is a 4% surcharge on all services requested by mail, email, phone or fax.

Card No. __ __ __ __ - __ __ __ __ - __ __ __ __ - __ __ __ __ Expiration Date: __ __/__ __

Card Code __ __ __ Cardholder’s Signature:

□ Frost Bank

Card No.500679-__ __ __ __ __-__ __ __-__ __

LegalEase

Client No.: __ __ __ __ __ __ Account Signature:

PLEASE PROVIDE TYPE OF SERVICE REQUESTED

□

)E PRO

Certified Copy of document on file (certified copies cannot be faxed or emailed to customer

□ Non-Certified Copy of document of file

Copies delivered by: □ Mail to address above

□ Fax to number above

□ Customer will pick up

□ Email to address above

* Some document(s) may exceed the outgoing email file size limitations

FOR COPY REQUEST - PROVIDE DOCUMENT *INFORMATION*

* Document Type, Date of document, Names on document, File number or license number*

For County Clerk Use Only:

Amount: $

Approval Code:__ __ __ __ __ __

Receipt #

Requested by: □ fax □ phone □ mail □ email

Entered by:

P.O. Box 1525  Houston, TX 77251-1525  PHONE 713-274-6390  FAX (713) 437-4868

 ccinfo@cco.hctx.net

Form No. B-02-19 (Rev. 06/01/2016)

Harris County Dba Form

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