Fillable Authorization for Credit Card Use (State of Alabama)

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Authorization for Credit Card Use (State of Alabama)

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U.S.A. forms for State of Alabama

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Authorization for Credit Card Use
Print and Complete This Authorization and Return
All information will remain confidential
N
ame on Card: _______________________________________________________
Billing Address: _______________________________________________________
Credit Card Type: ___ Visa ___ Mastercard ___ Discover ____ AmEx
C
redit Card Number: ________________________________________________
Expiration Date: ________________________________________________
Amount to Charge: $ __________
I authorize Secretary of State of Alabama to charge the amount listed above to the credit card
provided herein. I agree to pay for this purchase in accordance with the issuing bank cardholder
agreement.
C
ardholder-Please Sign and Date
S
ignature: ____________________________________________
Date: ____________________________________________
Printed Name: _____________________________________________
Return the completed and signed form to the following:
S
ecretary of State
Trademark Division
11 South Union Street
Suite 224
Montgomery, AL 36130
Revised 02/2018
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Authorization for Credit Card Use (State of Alabama)

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Completed 20 July 2020

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