Filing Instructions For The Revival Of A Nevada Corporation Or Limitedliability Company - Nevada Secretary Of State Page 3
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1
2
3DEAN HELLER
Credit Card Checklist
Secretary of State
(For Counter, Telephone, Fax and
101 North Carson Street, Suite 3
Mail Requests)
Carson City, Nevada 89701-4786
(775) 684 5708
Service Type:
Counter ________
Telephone ________
Mail ________
Fax ________
Expedite Service: (Requires additional fees)
PLEASE EXPEDITE __________
Card Type:
(the Secretary of State accepts only VISA or MasterCard)
VISA ________
or MasterCard ________
Customer Credit Card Number:
(Must be 16 digits)
Expiration Date:
Month
Year
Amount:
$
,
.
Cardholder Information:
Name
Street
City, State, Zip
Telephone
Reference Number: (supplied by machine)
Approval Number: (supplied by machine)
Employee Initials:
AUTHORIZATION:
CUSTOMER AUTHORIZES THE SECRETARY OF STATE TO BILL AN AMOUNT NOT TO
EXCEED $
.
TO BE CHARGED TO THE ABOVE CREDIT CARD
NUMBER.
(Cardholder signature)
Nevada Secretary of State Form CRCARD1999.01
Revised on: 03/06/00
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