Form DPR-105 "Visa/Mastercard Transaction" - California

What Is Form DPR-105?

This is a legal form that was released by the California Department of Pesticide Regulation - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2017;
  • The latest edition provided by the California Department of Pesticide Regulation;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DPR-105 by clicking the link below or browse more documents and templates provided by the California Department of Pesticide Regulation.

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Download Form DPR-105 "Visa/Mastercard Transaction" - California

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STATE OF CALIFORNIA
DEPARTMENT OF PESTICIDE REGULATION
1001 I STREET
SACRAMENTO, CA 95814-2828
Web site: http://www.cdpr.ca.gov
DPR-105 (Rev. 08/17)
Page 1 of 1
VISA/MASTERCARD TRANSACTION
Mail completed application with this payment form to:
For Licensees:
For Continuing Education Sponsors:
ATTN: Cashier
Cashier
Department of Pesticide Regulation
ATTN: CE
P.O. Box 4015
Department of Pesticide Regulation
Sacramento, CA 95812
P.O. Box 1379
Sacramento, CA 95812
ALL SECTIONS MUST BE COMPLETED. DO NOT E-MAIL OR FAX this form.
FAILURE TO COMPLETE ALL SECTIONS WILL RESULT IN YOUR APPLICATION BEING DELAYED OR REJECTED.
NAME OF CARDHOLDER (NAME APPEARING ON THE CARD)
VISA or MASTERCARD ONLY. No other cards are accepted.
CHECK ONE:
VISA
MASTERCARD
CARD NUMBER
(16 DIGITS)
Expiration Date
Total Amount of Payment
SIGNATURE OF CARDHOLDER (NAME APPEARING ON THE CARD)
PAYMENT FOR:
MAILING ADDRESS (Street or P.O. Box Number)
City, State, and ZIP Code
TELEPHONE NUMBER
(include area code)
(DEPARTMENT USE ONLY) - ENTERED ON POS BY:
TODAY'S DATE
DATE MAILED
BY:
STATE OF CALIFORNIA
DEPARTMENT OF PESTICIDE REGULATION
1001 I STREET
SACRAMENTO, CA 95814-2828
Web site: http://www.cdpr.ca.gov
DPR-105 (Rev. 08/17)
Page 1 of 1
VISA/MASTERCARD TRANSACTION
Mail completed application with this payment form to:
For Licensees:
For Continuing Education Sponsors:
ATTN: Cashier
Cashier
Department of Pesticide Regulation
ATTN: CE
P.O. Box 4015
Department of Pesticide Regulation
Sacramento, CA 95812
P.O. Box 1379
Sacramento, CA 95812
ALL SECTIONS MUST BE COMPLETED. DO NOT E-MAIL OR FAX this form.
FAILURE TO COMPLETE ALL SECTIONS WILL RESULT IN YOUR APPLICATION BEING DELAYED OR REJECTED.
NAME OF CARDHOLDER (NAME APPEARING ON THE CARD)
VISA or MASTERCARD ONLY. No other cards are accepted.
CHECK ONE:
VISA
MASTERCARD
CARD NUMBER
(16 DIGITS)
Expiration Date
Total Amount of Payment
SIGNATURE OF CARDHOLDER (NAME APPEARING ON THE CARD)
PAYMENT FOR:
MAILING ADDRESS (Street or P.O. Box Number)
City, State, and ZIP Code
TELEPHONE NUMBER
(include area code)
(DEPARTMENT USE ONLY) - ENTERED ON POS BY:
TODAY'S DATE
DATE MAILED
BY: