Form DPR-105-B "Continuing Education Sponsor Visa / Mastercard" - California

What Is Form DPR-105-B?

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:

  • 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-B by clicking the link below or browse more documents and templates provided by the California Department of Pesticide Regulation.

ADVERTISEMENT
ADVERTISEMENT

Download Form DPR-105-B "Continuing Education Sponsor Visa / Mastercard" - California

356 times
Rate (4.8 / 5) 25 votes
State of California
Department of Pesticide Regulation
1001 I Street
Sacramento, CA 95814-2828
Web site:
http://www.cdpr.ca.gov
DPR-105-B
Page 1 of 1
Continuing Education Sponsor Visa / Mastercard
Complete this payment form and mail with completed application form(s) to:
Cashier
ATTN: CE
Department of Pesticide Regulation
PO Box 1379
Sacramento, CA 95812
All sections must be completed. Do not e-mail or fax this form. Electronically received forms will not be
accepted.
Failure to complete all sections of this form may result in your application and payment being delayed or rejected.
Cardholder Information
Name
T elephone Number
(as it appears on the card)
(
)
Card Information.
(Visa and Mastercard only. No other cards are accepted)
Card Type
Visa
Mastercard
(check one):
--
--
--
Card Number
(16 digits):
/
Billing ZIP Code:
Expiration Date:
Total Amount of Payment: $
Signature o f Cardholder
Billing Address
(Street or PO Box Number)
City
State
ZIP Code
Please list below information for the course(s). Attach an additional sheet if needed.
Course Name:
Sponsor:
Course Name:
Sponsor:
(Department Use Only) – Entered on POS by:
Date Entered:
Date Mailed:
Mailed By:
Notes:
State of California
Department of Pesticide Regulation
1001 I Street
Sacramento, CA 95814-2828
Web site:
http://www.cdpr.ca.gov
DPR-105-B
Page 1 of 1
Continuing Education Sponsor Visa / Mastercard
Complete this payment form and mail with completed application form(s) to:
Cashier
ATTN: CE
Department of Pesticide Regulation
PO Box 1379
Sacramento, CA 95812
All sections must be completed. Do not e-mail or fax this form. Electronically received forms will not be
accepted.
Failure to complete all sections of this form may result in your application and payment being delayed or rejected.
Cardholder Information
Name
T elephone Number
(as it appears on the card)
(
)
Card Information.
(Visa and Mastercard only. No other cards are accepted)
Card Type
Visa
Mastercard
(check one):
--
--
--
Card Number
(16 digits):
/
Billing ZIP Code:
Expiration Date:
Total Amount of Payment: $
Signature o f Cardholder
Billing Address
(Street or PO Box Number)
City
State
ZIP Code
Please list below information for the course(s). Attach an additional sheet if needed.
Course Name:
Sponsor:
Course Name:
Sponsor:
(Department Use Only) – Entered on POS by:
Date Entered:
Date Mailed:
Mailed By:
Notes: