Credit Card/debit Card Authorization Form
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1Attach this form to your document, certificate or other written request.
The Name of the Corporation or Business Entity to Which This Request Applies is:
Check Box for Requested Service:
Fill in Fee or Amount:
(
$ _________________
FILING OF DOCUMENT OR CERTIFICATE
Consult appropriate fee schedule for fee)
Check the appropriate box:
Routine Processing:
No additional fee
$ _________________
Expedited Processing:
24-Hour Additional $25 fee
Same Day Additional $75 fee
2-Hour Additional $150 fee
(
$ _________________
CERTIFIED COPY
The fee for each certified copy is $10)
Check the appropriate box:
Routine Processing:
No additional fee
$ _________________
Expedited Processing:
24-Hour Additional $25 fee
Same Day Additional $75 fee
2-Hour Additional $150 fee
(
$ _________________
PLAIN COPY
The fee for each plain copy is $5)
Check the appropriate box:
Routine Processing:
No additional fee
$ _________________
Expedited Processing:
24-Hour Additional $25 fee
Same Day Additional $75 fee
2-Hour Additional $150 fee
(
$ _________________
CERTIFICATE OF STATUS
Certificates of Good Standing, etc. The fee for each certificate is $25.)
Check the appropriate box:
Routine Processing:
No additional fee
$ _________________
Expedited Processing:
24-Hour Additional $25 fee
Same Day Additional $75 fee
2-Hour Additional $150 fee
$ _________________
SERVICE OF PROCESS
(Must be served in person at the above address)
$ _________________
BIENNIAL / FIVE YEAR STATEMENT
OTHER
$ _________________
DEPOSIT TO DRAWDOWN
:
$ _________________
Account Name:
Account Number:
$ _________________
TOTAL
(Total Amount Due)
Same Day expedited service requests must be received by 12 noon on regular business days.
2-hour expedited service requests must be received by 2:30 p.m. on regular business days.
Expedited processing fees are charged even if a document, certificate or other request is rejected as deficient.
Credit/Debit Card Information:
MasterCard
Visa
American Express
TYPE OR PRINT CLEARLY
Card Number: ______________________________________________________ Expiration Date (Month/Year): ________________
Name as it Appears
on Card:
Cardholder’s Billing Address:
City: _______________________________________________ State:
Zip Code: ______________________
Fax Number:
Cardholder’s Signature:
Date:
If the name on the card is in the name of a corporation or
other business entity, please print the signer’s name:
DOS-1515-f (Rev. 04/16)
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Parent category: Business