Credit Card Authorization Form - Georgia

Credit Card Payment Authorization Form
Instructions: To pay by credit card, please complete both sections below.
CREDIT CARD HOLDER INFORMATION
Please check credit card type:
Visa MasterCard Discover American Express
Credit card number: _____________________________ Expiration date :__________/__________( mm/yy )
Exact name as it appears on the credit card: _________________________________________________________
Billing Zip Code: _________________________________ Amount to be charged: $ _____________________
Primary phone number: ______________________________ Secondary phone number: ____________________
Cardholder Signature: _______________________________________ Date: ___________________
LICENSEE/DRIVER INFORMATION
Name as it appears on Driver's License/ID: _________________________________________________________
Licensee's Drivers License / ID number: ___________________________________________________________
Birth date: ___________ /__________ /____________ (mm/dd/yyyy)
Gender (circle one): Male Female
Please send this credit/debit card payment form and supporting documents to:
Georgia Department of Driver Services
ATTN: Validation
P. O. Box 80447
Conyers, GA 30013
What type of service is this payment for?
DDS-100 12/08
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Credit Card Authorization Form - Georgia PDF

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