Credit Card Checklist (For Counter, Telephone, Fax And Mail Requests) - Nevada Secretary Of State
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1DEAN HELLER
Credit Card Checklist
Secretary of State
(For Counter, Telephone, Fax and
202 North Carson Street
Mail Requests)
Carson City, Nevada 89701-4201
(775) 684 5708
Website: secretaryofstate.biz
Service Type:
Counter
Telephone
Mail
Fax
Expedite Service: (Requires additional fees) PLEASE EXPEDITE 24-HOUR SERVICE
2-HOUR SERVICE
Card Type:
(the Secretary of State accepts only VISA or MasterCard)
VISA
or MasterCard
Customer Credit Card Number:
(Must be 16 digits)
V CODE
(LAST 3 DIGITS ON
BACK OF CREDIT CARD)
Expiration Date:
Month
Year
Amount:
$
,
.
Cardholder Information:
Entity Name ___________________________________________________________________________
Name
Billing Address
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.
X
CARDHOLDER SIGNATURE
Nevada Secretary of State Form CRCARD 2003
Revised on: 10/24/03
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