Name Based Criminal Background Check Form - Idaho State Police Bureau Of Criminal Identification Page 2

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Idaho State Police
Bureau of Criminal Identification
CREDIT CARD AUTHORIZATION FORM
***Please note: There is an additional processing fee of $1.00 plus 3% of the total transaction for all
payments made by credit or debit card. ***
Credit Card (If paying by credit or debit card, complete the following)*
Name of applicant/subject(s) of record
Requestor/Agency
Credit Card Type
Visa
AmEx
MasterCard
Discover
-
-
-
Credit Card Number:
/
Expiration Date:
Zip Code (Required):
Name as it appears on card:
Phone Number:
(Phone number required, in case we need clarification or have questions regarding payment)
Email:______________________________________________
(If you prefer your receipt to be emailed, please provide a legible email address)
Signature of Payee
:
(Required before mailing or faxing)
Electronic signatures will not be accepted
Phone: (208) 884-7130
Fax: (208) 884-7193
700 S. Stratford Dr., Ste. 120
Meridian, ID 83642

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