Payment / Billing Payment Authorization FormCompany InformationCompany Name(Required) Contact Phone(Required)Contact / Confirmation Email(Required) Enter Email Confirm Email Payment InformationResale PermitTotal Credit Card(Required) American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Expiration Date Month Month010203040506070809101112 Year Year20242025202620272028202920302031203220332034203520362037203820392040204120422043 Security Code Cardholder Name Billing Address(Required) Street Address City ZIP Code Credit Card Authorization Consent Agreement(Required) ***** Please scroll and read and agree to the Credit Card Authorization Consent Agreement I am an authorized user of the credit card. “ I “ refers to the cardholder / authorized user. I understand my card will be pre-authorized, and a hold will be placed on the credit card for the exact amount of the charge. I understand the information is verified on the application for errors. At times, the information verification process may add additional time. I understand this may create a delay in the processing of the application. I understand as this is a unique service for the business information entered, and a refund will be issued only if the business is registered, or if the application for the company is rejected; if this applies to your application, your card will either not be charged or will be refunded. I understand the information must be verified on the application submitted, and any errors, intentional or otherwise, may create a delay in the processing of your application. Once the application is reviewed and the application is processed, I understand I will receive an email confirmation, at which point my credit card will be charged. I am authorizing a single, one (1) time credit card charge to be processed through License Tax Sales Services. I understand no additional charges will be authorized, and only the last four digits of the credit card are kept on file, solely for record keeping purposes. I authorize a charge for the above amount to the credit card indicated in this authorization form according to the terms outlined above. This payment authorization is for the services described above, for the amount indicated above only, and is valid for one time use only. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company; so long as the transaction corresponds to the terms indicated in this form. This authorization is for a single transaction only, and does not provide authorization for any additional unrelated debits or credits to your account. Accept Consent for Credit Card Authorization Consent AgreementSignature(Required) Δ
