"Credit Card Authorization Form" - Nevada

Credit Card Authorization Form is a legal document that was released by the Nevada Department of Education - a government authority operating within Nevada.

Form Details:

  • Released on April 1, 2016;
  • The latest edition currently provided by the Nevada Department of Education;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Nevada Department of Education.

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Las Vegas Office
Carson City Office
9890 South Maryland Parkway
755 N Roop Street
Suite 221
Suite 107
Las Vegas, Nevada 89183
Carson City, Nevada 89701
702-486-6458
775-687-5980
Educator Licensure
Serving Clark, Lincoln and
Serving all other Nevada
Nye Counties
license@doe.nv.gov
counties
State of Nevada
Department of Education
Credit Card Authorization Form
Printed Name (as it appears on your credit card): ________________________________________________
Billing Address: _________________________________________________________________________
Street Address/P.O. Box
City
State
Zip Code
Nevada Educator License Number (if applicable): ___________________ Telephone: _______________________
Email Address: _________________________________________________________________________________
Payment Type ☐ Discover
☐ Master Card
☐ Visa
Payment Amount: $________________
Debit or Credit Card Number:
Account Number(16 digits): __________________________________________
Exp. Date: ____/____ CVV/CID: _______
I understand and agree that I am authorizing the Nevada Department of Education to charge my account. The
payment amount may not exceed the amount above. I certify that I am an authorized user and will not dispute the
payment with my credit card company so long as the transaction corresponds to the terms indicated in the form.
Authorized Signature: _______________________________________________ Date: _________________
__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
For Official Use Only
Please attach licensure audit receipt here
Rev Apr 2016
Las Vegas Office
Carson City Office
9890 South Maryland Parkway
755 N Roop Street
Suite 221
Suite 107
Las Vegas, Nevada 89183
Carson City, Nevada 89701
702-486-6458
775-687-5980
Educator Licensure
Serving Clark, Lincoln and
Serving all other Nevada
Nye Counties
license@doe.nv.gov
counties
State of Nevada
Department of Education
Credit Card Authorization Form
Printed Name (as it appears on your credit card): ________________________________________________
Billing Address: _________________________________________________________________________
Street Address/P.O. Box
City
State
Zip Code
Nevada Educator License Number (if applicable): ___________________ Telephone: _______________________
Email Address: _________________________________________________________________________________
Payment Type ☐ Discover
☐ Master Card
☐ Visa
Payment Amount: $________________
Debit or Credit Card Number:
Account Number(16 digits): __________________________________________
Exp. Date: ____/____ CVV/CID: _______
I understand and agree that I am authorizing the Nevada Department of Education to charge my account. The
payment amount may not exceed the amount above. I certify that I am an authorized user and will not dispute the
payment with my credit card company so long as the transaction corresponds to the terms indicated in the form.
Authorized Signature: _______________________________________________ Date: _________________
__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
For Official Use Only
Please attach licensure audit receipt here
Rev Apr 2016