Credit Card Checklist - Nevada Secretary Of State

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ROSS MILLER
Credit Card Checklist
Secretary of State
202 North Carson Street
(For Counter, Telephone, Fax and
Carson City, Nevada 89701-4201
Mail Requests)
(775) 684 5708
Website: secretaryofstate.biz
USE BLACK INK ONLY - DO NOT HIGHLIGHT
Service Type:
Counter
Telephone
Mail
Fax
Expedite Service: (Requires additional fees)
2-HOUR SERVICE
1-HOUR SERVICE
24-HOUR SERVICE
PLEASE EXPEDITE:
Card Type: (Mark one box)
American Express
VISA
MasterCard
Discover
Customer Credit Card Number:
*
V CODE
*
3-digit number found on the far right of the backside of VISA, MasterCard and Discover cards
4-digit number found on the front right side of American Express card.
NOTICE: For security and verification purposes, all credit card payments must include the 3 or 4-digit CVV2 code
(VCode) number located on the credit card. Failure to include this code will result in the rejection of your filing or
service request.
Expiration Date:
Month
Year
Amount:
$
Cardholder Information:
Entity Name
Name
Billing Address
City, State, Zip
Telephone
AUTHORIZATION:
CUSTOMER AUTHORIZES THE SECRETARY OF STATE TO BILL AN AMOUNT NOT TO
EXCEED $
TO BE CHARGED TO THE ABOVE CREDIT CARD
NUMBER.
X
CARDHOLDER SIGNATURE
Nevada Secretary of State Form Credit Card 2007
Reset
Revised on: 06/05/07

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