T:\Licensing\New License Applications and forms\New License Application\Forms\Revised 2018\03.19.2018
Arizona Medical Board
1740 W. Adams St. Suite 4000 Phoenix, AZ 85007-2664
PAYMENT CARD AUTHORIZATION
DUPLICATE LICENSE FEE: $50
(Wall Certificate)
Name as Shown on Payment Card:
(No dashes between numbers)
Expiration Date:
Card Number:
AmexMastercardVisa
Type of Card:
Payment for: License #:
(Physician Name)
Billing Address of Cardholder:
(Required)
Phone Number of Cardholder:
Zip:State:City:
Zip:State:City:
(If different from billing address)
Mailing Address of Cardholder:
(Required)
Date:
(Required)
The Arizona Medical Board will only accept credit card payment via mail (USPS, FedEx, UPS, or any
other mail carrier). Any credit card information received via any other method will not be
processed and will be destroyed.
Please complete and return this form with your payment (credit card form, check or money order)
to the address listed below
Mail to: Arizona Medical Board
1740 W. Adams St. Ste. 4000
Phoenix, AZ 85007-2664
Signature:
