Form Dos-1515 - Credit Card Authorization
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1NYS Department of State
41 State Street
DIVISION OF CORPORATIONS
Albany, NY 12231-0001
Credit Card Authorization
The Department of State’s Division of Corporations accepts Master Card and Visa for payment of certain fees. To pay the fee for this
transaction using a credit card, simply complete and sign this page and attach it to your request and certificate, if applicable. (Please note,
omission of information may cause delay in the processing of your request.)
PLEASE INDICATE TRANSACTION TYPE:
SUMMONS
STATEMENT
DEPOSIT TO DRAWDOWN ACCOUNT
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
FILING
(Please refer to fee schedule for specific filing fee)
Please indicate level of service with an X
Q
Q
Q
Q
Routine
24 hr-$25
Same day - $75 must be received prior to 2:01 pm
2 hr - $150
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
COPIES-Type & Quantity:
Certified Copy ($10 each)
CERTIFICATE UNDER SEAL ($25 each)
Plain Copy ($5 each)
Please indicate level of service with an X
Q
Q
Q
Q
24 hr-$25
Same day - $75 must be received prior to 2:01 pm
2 hr - $150
Routine
Entity Name:
Total Amount Due: $
If a service company indicate name and number:
We currently are able to honor cards issued by Master Card and Visa only. Please charge to the following credit card:
Q
Q
Master Card
Visa
Expiration Date: (Month)
(Year)
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Credit card number:
CARDHOLDER’S NAME (PRINT)
CARDHOLDER’S BILLING ADDRESS AS LISTED WITH CREDIT CARD COMPANY
CITY
STATE
ZIP CODE+4
Cardholder’s Signature
Date
If there is a problem processing this credit card, we would like to be able to reach you.
OPTIONAL:
Fax telephone number:
Daytime telephone number:
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F O R O F F I C E
U S E
O N L Y
AUTHORIZATION NO.
FILM NUMBER
CASH NUMBER
DOCUMENT IDENTIFICATION NUMBER
DATE
CORP. ID NUMBER
REQUEST NUMBER
DOS-1515 (Rev. 3/01)
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