Initial Firm Registration - Oregon Board Of Accountancy Page 8

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11
CREDIT/DEBIT CARD PAYMENT AUTHORIZATION FORM
~MUST ACCOMPANY FIRM REGISTRATION APPLICATION~
I authorize the Oregon Board of Accountancy to charge my credit/debit card listed below, and if necessary, to
initiate adjustments for any transactions credited or debited in error.
DO NOT SEPARATE THIS SHEET FROM YOUR APPLICATION FORM.
Name
Date
Signature
CARDHOLDER’S INFORMATION: (Please PRINT and provide ALL information.)
Charge Amount:
VISA OR MasterCard
Expiration Date:
Card Number:
Cardholder Name (as it appears on the card):
Cardholder Billing Address:
Cardholder’s Signature
Date
If paying by CHECK, make check payable to:
If paying by CREDIT CARD, you may mail or fax
to:
Oregon Board of Accountancy
Oregon Board of Accountancy
MAIL TO:
Mail to:
Oregon Board of Accountancy
Unit 05
Oregon Board of Accountancy
PO Box 4395
3218 Pringle Rd SE #110
Portland, OR 97208-4395
Salem OR 97302
OR
FAX: 503-378-3575
DO NOT EMAIL THE APPLICATION FORM OR PAYMENT SHEET.
2015 INITIAL FIRM REGISTRATION PG 5
Questions? Please contact: (503) 378-2264 / angel.m.legler@oregon.gov or kimberly.fast@oregon.gov / 503-378-2268

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