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 (excluding DCJS fingerprint fees). To pay fees using a credit card, simply complete and sign this page and attach it to your application form. 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. LAST NAME FIRST NAME MIDDLE NAME COMPANY NAME CREDIT CARD INFORMATION NAME AS IT APPEARS ON CREDIT CARD STREET ADDRESS APT/UNIT/PO BOX CITY STATE ZIP+4 Total Amount Due: $ Please charge to the following credit card: MasterCard 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 American LegalNet, Inc. www.FormsWorkFlow.com DOS-1450 (1/04) G G Visa Expiration Date: (Month) _____ (Year) ______