Fillable Printable Credit Card Authorization Form - Georgia

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