Fillable Printable Credit Card Authorization Form Template

Credit Card Authorization Form Template

DOS-1450-f-l-a (03/10)

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.

APPLICANT’S INFORMATION

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: ( ) -

Cardholder’s Signature:

Date:

LAST NAME:

FIRST NAME:

COMPANY NAME:

UNIQUE I.D.NUMBER (If applicable)

MIDDLE NAME:

NAME AS IT APPEARS ON CARD:

STREET ADDRESS:

APT / UNIT / PO BOX:

CITY: STATE: ZIP+4:

MasterCard Visa

Total Amount Due: $

Expiration Date:

(Month) (Year)