Credit Card Authorization Form - Division Of Licensing Services
Download a blank fillable Credit Card Authorization Form - Division Of Licensing Services in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Credit Card Authorization Form - Division Of Licensing Services with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1Department of State
Credit Card Authorization
Division of Licensing Services
P.O. Box 22001
Albany, NY 12201-2001
The Department of State’s Division of Licensing Services accepts MasterCard and Visa for
payment of fees. To pay fees using a credit card, simply complete and sign this form and attach
it to your application.
We process credit card payments upon receipt.
Please PRINT CLEARLY in blue or black ink.
APPLICANT’S INFORMATION
Please enter the name of the person or company this payment is being made for.
LAST NAME:
FIRST NAME:
MIDDLE NAME:
COMPANY NAME:
UNIQUE I.D.NUMBER (If applicable)
CREDIT CARD INFORMATION
NAME AS IT APPEARS ON CARD:
STREET ADDRESS:
APT / UNIT / PO BOX:
CITY:
STATE:
ZIP+4:
Total Amount Due: $
Please charge to the following credit card:
MasterCard
Visa
Expiration Date:
(Month)
(Year)
Credit Card No.:
-
-
-
If there is a problem processing this payment, we would like to be able to reach you by phone.
Optional: Daytime telephone number: (
)
-
Cardholder’s Signature:
Date:
DOS-1450-f-l-a (03/10)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business