"Credit Card Authorization Form" - Delaware

This "Credit Card Authorization Form" is a Delaware-specific form released by the Delaware Department of Agriculture on August 7, 2001.

Download the form by clicking the link below, fill it out by hand, and mail it as per the guidelines provided by the department or the applicable legal instructions.

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Download "Credit Card Authorization Form" - Delaware

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State of Delaware
Telephone
(302) 698-4500
Department of Agriculture
DE Only
(800) 282-8685
Pesticide Compliance
Fax
(302) 697-4483
2320 S. DuPont Hwy. Dover, DE 19901
Credit Card Authorization Form
VISA
MASTERCARD
DISCOVER
PLEASE TYPE OR PRINT
Date:
Name:
Address:
City:
State:
Zip Code :
Phone Number:
Credit Card Number:
CVC # on back (3 or 4 digits) _________
Expiration Date:
/
/
Authorized Signature:
Description of Payment
Amount
$
$
$
$
$
TOTAL:
$
Document No. 65-01-06/01/08/07
State of Delaware
Telephone
(302) 698-4500
Department of Agriculture
DE Only
(800) 282-8685
Pesticide Compliance
Fax
(302) 697-4483
2320 S. DuPont Hwy. Dover, DE 19901
Credit Card Authorization Form
VISA
MASTERCARD
DISCOVER
PLEASE TYPE OR PRINT
Date:
Name:
Address:
City:
State:
Zip Code :
Phone Number:
Credit Card Number:
CVC # on back (3 or 4 digits) _________
Expiration Date:
/
/
Authorized Signature:
Description of Payment
Amount
$
$
$
$
$
TOTAL:
$
Document No. 65-01-06/01/08/07
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