Form C-4 "Credit Card Authorization Form" - Pennsylvania

What Is Form C-4?

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

Form Details:

  • Released on May 1, 2012;
  • The latest edition provided by the Pennsylvania Department of Transportation;
  • 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 C-4 by clicking the link below or browse more documents and templates provided by the Pennsylvania Department of Transportation.

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Download Form C-4 "Credit Card Authorization Form" - Pennsylvania

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C-4 (5-12)
CREDIT CARD AUTHORIZATION FORM
O F F I C E O F T H E CO M P T R O L L E R
FAX NO: (717) 346-0494 To confirm receipt of form, call: (717) 425-6724 All other inquiries: (717) 214-7024
A
CARDHOLDER INFORMATION
In order for us to accept and promptly process your payment by credit card, all of the following
information must be submitted:
Type of card being used:
Mastercard
Visa
Discover
American Express
Expiration date of card:
Account Number Listed on Card:
(mm/yy)
Card Holder Name
Cardholder Street Address
City
State
Zip Code
Telephone Number
B
AUTHORIZATION
I, ________________________________________, authorize the Pennsylvania Department of
(Name of Cardholder)
Transportation to charge my above listed credit card for $ _________________ for the payment
of the following invoice numbers:
Invoice 1:
Invoice 2:
Invoice 3:
Invoice 4:
Invoice 5:
Invoice 6:
C
APPROVAL SIGNATURE
Signature of Cardholder
Date (mm/dd/yyyy)
C-4 (5-12)
CREDIT CARD AUTHORIZATION FORM
O F F I C E O F T H E CO M P T R O L L E R
FAX NO: (717) 346-0494 To confirm receipt of form, call: (717) 425-6724 All other inquiries: (717) 214-7024
A
CARDHOLDER INFORMATION
In order for us to accept and promptly process your payment by credit card, all of the following
information must be submitted:
Type of card being used:
Mastercard
Visa
Discover
American Express
Expiration date of card:
Account Number Listed on Card:
(mm/yy)
Card Holder Name
Cardholder Street Address
City
State
Zip Code
Telephone Number
B
AUTHORIZATION
I, ________________________________________, authorize the Pennsylvania Department of
(Name of Cardholder)
Transportation to charge my above listed credit card for $ _________________ for the payment
of the following invoice numbers:
Invoice 1:
Invoice 2:
Invoice 3:
Invoice 4:
Invoice 5:
Invoice 6:
C
APPROVAL SIGNATURE
Signature of Cardholder
Date (mm/dd/yyyy)