"One Time Credit Card Payment Authorization Form" - New York

One Time Credit Card Payment Authorization Form is a legal document that was released by the New York State Department of Agriculture and Markets - a government authority operating within New York.

Form Details:

  • The latest edition currently provided by the New York State Department of Agriculture and Markets;
  • 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 New York State Department of Agriculture and Markets.

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Download "One Time Credit Card Payment Authorization Form" - New York

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ANDREW M. CUOMO
RICHARD A. BALL
Governor
Commissioner
One Time Credit Card Payment Authorization Form
Dealer’s Business Name: ___________________________________________
Sign and complete this form to authorize the NYS Department of Agriculture and Markets to make a one-time debit to your
credit card listed below. Please mail to this form to: NYS Department of Agriculture & Markets, Division of Agricultural
Development, 10B Airline, Albany, NY 12235.
.
By signing this form you give us permission to debit your account for the amount indicated on or after the indicated date.
This is permission for a single transaction only, and does not provide authorization for any additional unrelated debits or
credits to your account
Please complete the information below:
I, _________________________________, authorize the NYS Department of Agriculture and Markets to
charge my credit card account indicated below for $
. This payment is for a:
FARM PRODUCTS DEALER LICENSE
Billing Address
_____________________________________
Phone No.: _______________________
City ________________________________________________
State__________ Zip _____________
Email __________________________________________________________________________________________
FOR OFFICE USE ONLY
Account Type:
Visa
MasterCard
AMEX
Discover
Cardholder Name _______________________________________________
Estab No.: ______________
Account Number _______________________________________________
License No: ______________
Expiration Date
_______________________________________________
Receipt No: _____________
CVV2 (3 digit number on back of Visa/MC, 4 digits on front of AMEX)
Validation No: ____________
___________
SIGNATURE _________________________________________________
DATE ___________________________
I authorize the NYS Department of Agriculture and Markets to charge the credit card indicated in this authorization
form according to the terms outlined above. This payment authorization is for a Farm Products Dealer license, 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.
ANDREW M. CUOMO
RICHARD A. BALL
Governor
Commissioner
One Time Credit Card Payment Authorization Form
Dealer’s Business Name: ___________________________________________
Sign and complete this form to authorize the NYS Department of Agriculture and Markets to make a one-time debit to your
credit card listed below. Please mail to this form to: NYS Department of Agriculture & Markets, Division of Agricultural
Development, 10B Airline, Albany, NY 12235.
.
By signing this form you give us permission to debit your account for the amount indicated on or after the indicated date.
This is permission for a single transaction only, and does not provide authorization for any additional unrelated debits or
credits to your account
Please complete the information below:
I, _________________________________, authorize the NYS Department of Agriculture and Markets to
charge my credit card account indicated below for $
. This payment is for a:
FARM PRODUCTS DEALER LICENSE
Billing Address
_____________________________________
Phone No.: _______________________
City ________________________________________________
State__________ Zip _____________
Email __________________________________________________________________________________________
FOR OFFICE USE ONLY
Account Type:
Visa
MasterCard
AMEX
Discover
Cardholder Name _______________________________________________
Estab No.: ______________
Account Number _______________________________________________
License No: ______________
Expiration Date
_______________________________________________
Receipt No: _____________
CVV2 (3 digit number on back of Visa/MC, 4 digits on front of AMEX)
Validation No: ____________
___________
SIGNATURE _________________________________________________
DATE ___________________________
I authorize the NYS Department of Agriculture and Markets to charge the credit card indicated in this authorization
form according to the terms outlined above. This payment authorization is for a Farm Products Dealer license, 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.