Form Vp013 - Application For Duplicate Certificate Of Registration And/or Substitute Dacal Page 2

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555 Wright Way

Please remit $6.00 for each Registration Certificate.

Carson City, NV 89711

Reno/Sparks/Carson City (775) 684-4DMV (4368)

If ordering by mail, you may also remit a check

Las Vegas area (702) 486-4DMV (4368)

or money order.

Rural Nevada or Out of State (877) 368-7828

Payment Type:

Master Card

Visa

Discover Card

Payment Amount

Debit or Credit Card Number

(one number per box)

Please Print or Type

Cardholder Information

Expiration Date

Printed Name

Print your name as it appears on your card

Month

Year

Mailing Address

Street / P.O. Box

City

State

Zip Code

Plate/Driver Lic./Bus. Lic./Records/MC Number

of the transaction being processed.

Telephone

Authorized Signature

Date

By signing this form, you give us permission to debit your account for the amount indicated on or after the indicated date.

VP-205 (Rev. 5/2017)

I authorize the DMV to charge the credit/debit card indicated in this authorization form according to the terms outlined above. This payment authorization is for the

amount indicated above only and is valid for one-time use only. I certify that I am an authorized user of this credit/debit card and that I will not dispute the payment

with my credit/debit card company so long as the transaction corresponds to the terms indicated in the form.

*Printed form is 3.5” x 7.5”