hereby authorize this card to be used for the deposit and/or. Printed Name final payment for Invoice(s) ______. ... Secu
Please complete the top half of this form and fax to A & N with payment instructions. A confirmation of the final ch
CREDIT CARD AUTHORIZATION FORM. Card Holder Information. Card Type (check one):. MasterCard. American Express. Name (as
I, the designated cardholder of the above listed card, authorize MicroAge to charge the amount of $______ to the above l
2122 24th Place NE Washington DC P: 202.808.8600 F: 202.808.8299 E: ... consent to the use of my credit card without my
By signing below, I certify that I am authorized to make charges to the credit card below. ... MAIL FORM or FAX TO SECUR
Celebration Club accepts Visa, American Express, and MasterCard. If you wish to pay your invoice with a credit card, a 3
Celebration Club accepts Visa, American Express, and MasterCard. If you wish to pay your invoice with a credit card, a 3
Whether you already accept credit card payments from clients or you're ... and simplify your billing experience, our fir
Form G-1450 08/06/15. Page 1 of 1. Complete the "Applicant's Information," "
Credit Card Billing Information," and "Credit Card Information" sections and sign.
Fax: 416-967-6320 OR email: [email protected]. I, the undersigned, am the card holder of the credit card specified bel
(To be used by Hotel Guest/External Guest). This is to authorize the Centro
Rotana, Yas Island to bill the hotel invoice of: Guest Name : ANDREA
NISSOLINO.
Postal code: Country: Phone: Email: Please complete and return by. Fax: 416-967-6320 OR email: [email protected]. I, t
1-786 (1-31-10). Credit Card Payment Form. * Denotes Required Fields.
Applicant Name. * Name. (as it appears on credit card). Company Name (if
applicable).
Circle one: VISA. MASTERCARD. AMERICAN EXPRESS. DISCOVER. 3-Digit Security Code: ___ ___ ___. AMEX 4-Digit Security Code
RECEIVED BY ACCOUNT MANAGER POSTED BY DATE. HST REGISTRATION #: 8197-08926-RP0001. Page 1 of 1. Credit Card Authorizatio
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Phone: 800-275-6387. Fax: 713-266-3893. Salesperson ______. Sales
Associate ______. Please Fax back to: 713-266-3893. Credit Card Authorization.
CREDIT CARD DONATION FORM. Tel: 03-4256 5312 | Fax: 4252 8382 | [email protected] | Visit us at www.spca.org.my. SPC
20 hari dari tarikh penyata, dengan syarat tiada baki tertunggak dalam akaun kad
.... IC. BJR. PO BOX. STAFF. SE STAFF. Appr/Dec/Canx: Appr/Dec/Canx:.
Daytime telephone number: Fax number: Credit Card Number: NYS Department
of State. DIVISION OF CORPORATIONS. Credit Card/Debit Card Authorization.
NYS Department of State DIVISION OF CORPORATIONS
One Commerce Plaza, 99 Washington Ave. Albany, NY 12231-0001 www.dos.ny.gov
Credit Card/Debit Card Authorization Attach this form to your document or written request.
(Clears all text entry fields)
Reset Form
The Name of Corporation or Other Business Entity To Which This Service Request Applies is: Check Box for Requested Service: FILING OF DOCUMENTS AND CERTIFICATES Routine Service (No Charge), OR Expedited Service:
CERTIFIED COPY
Fill in Fee or Amount: (Consult appropriate fee schedule for filing fees)
$
24-Hour-$25
$
*Same-Day-$75
**2-Hour-$150
$
(The fee for each certified copy is $10.)
Routine Service (No Charge), OR Expedited Service:
PLAIN COPY (The fee for each plain copy is $5.)
$
**2-Hour-$150
$ $
(Certificates of Good Standing, etc. The fee for each certificate is $25.)
$
Routine Service (No Charge), OR Expedited Service:
SERVICE OF PROCESS
*Same-Day-$75
**2-Hour-$150
Routine Service (No Charge), OR Expedited Service:
CERTIFICATE UNDER SEAL
24-Hour-$25
24-Hour-$25
24-Hour-$25
*Same-Day-$75
*Same-Day-$75
$
**2-Hour-$150
$
(Must be served in person at the above address)
BIENNIAL / FIVE YEAR STATEMENT
$
OTHER
$
DEPOSIT TO DRAWDOWN
$
Account Name:
TOTAL (Total Amount Due):
Account Number:
$
*Same day expedited service requests must be received by 12 noon. **2-hour expedited service requests must be received by 2:30 p.m. Expedited service fees are non-refundable and will not be refunded if a filing is rejected.
Credit/Debit Card Information: MasterCard
Visa
American Express
Credit Card Number: Expiration Date (Month and Year): Name as it Appears on Credit Card or Debit Card (Print): Cardholder’s Billing Address (As listed with Credit Card or Debit Card Company): City:
State:
Zip Code+4: Date:
Cardholder’s Signature: If the name on the credit card or debit card is in the name of a corporation or other business entity, please print the signer’s name: Daytime telephone number: DOS-1515-f-l (Rev. 05/13)
