Credit Card Authorization Form Template
Credit Card Authorization
Department of State
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.
Please enter the name of the person or company this payment is being made for.
CREDIT CARD INFORMATION
Please charge to the following credit card:
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: ( ) -
UNIQUE I.D.NUMBER (If applicable)
NAME AS IT APPEARS ON CARD:
APT / UNIT / PO BOX:
CITY: STATE: ZIP+4:
Total Amount Due: $
Credit Card Authorization Form Template PDF
Favor this template? Just fancy it by voting!
1 Page(s) | 730 Views | 9 Downloads
1 Page(s) | 637 Views | 4 Downloads
1 Page(s) | 1097 Views | 17 Downloads
1 Page(s) | 5554 Views | 183 Downloads