Form DOS-1450-F-L-A "Credit Card Authorization Form" - New York

What Is Form DOS-1450-F-L-A?

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

Form Details:

  • Released on March 1, 2010;
  • The latest edition provided by the New York State Department of State;
  • 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 DOS-1450-F-L-A by clicking the link below or browse more documents and templates provided by the New York State Department of State.

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Download Form DOS-1450-F-L-A "Credit Card Authorization Form" - New York

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Department of State
Credit Card Authorization
Division of Licensing Services
P.O. Box 22001
Albany, NY 12201-2001
The Department of State’s Division of Licensing Services accepts MasterCard and Visa for
payment of fees. To pay fees using a credit card, simply complete and sign this form and attach
it to your application.
We process credit card payments upon receipt.
Please PRINT CLEARLY in blue or black ink.
APPLICANT’S INFORMATION
Please enter the name of the person or company this payment is being made for.
LAST NAME:
FIRST NAME:
MIDDLE NAME:
COMPANY NAME:
UNIQUE I.D.NUMBER (If applicable)
CREDIT CARD INFORMATION
NAME AS IT APPEARS ON CARD:
STREET ADDRESS:
APT / UNIT / PO BOX:
CITY:
STATE:
ZIP+4:
Total Amount Due: $
Please charge to the following credit card:
MasterCard
Visa
Expiration Date:
(Month)
(Year)
Credit Card No.:
-
-
-
If there is a problem processing this payment, we would like to be able to reach you by phone.
Optional: Daytime telephone number: (
)
-
Cardholder’s Signature:
Date:
DOS-1450-f-l-a (03/10)
Department of State
Credit Card Authorization
Division of Licensing Services
P.O. Box 22001
Albany, NY 12201-2001
The Department of State’s Division of Licensing Services accepts MasterCard and Visa for
payment of fees. To pay fees using a credit card, simply complete and sign this form and attach
it to your application.
We process credit card payments upon receipt.
Please PRINT CLEARLY in blue or black ink.
APPLICANT’S INFORMATION
Please enter the name of the person or company this payment is being made for.
LAST NAME:
FIRST NAME:
MIDDLE NAME:
COMPANY NAME:
UNIQUE I.D.NUMBER (If applicable)
CREDIT CARD INFORMATION
NAME AS IT APPEARS ON CARD:
STREET ADDRESS:
APT / UNIT / PO BOX:
CITY:
STATE:
ZIP+4:
Total Amount Due: $
Please charge to the following credit card:
MasterCard
Visa
Expiration Date:
(Month)
(Year)
Credit Card No.:
-
-
-
If there is a problem processing this payment, we would like to be able to reach you by phone.
Optional: Daytime telephone number: (
)
-
Cardholder’s Signature:
Date:
DOS-1450-f-l-a (03/10)