03/2018
CREDIT CARD PAYMENT FORM
Name of Physician:____________________________________________, D.O. License No. __________________
Item/Service Requested:_________________________________________ Amount $ ___________________
We do not accept fax or email. Payment must be mailed with this request.
Arizona Board of Osteopathic Examiners In Medicine and Surgery
1740 W. Adams Street, Suite 2410, Phoenix, Arizona, 85007
Ph : 480-657-7703 | www.azdo.gov
_____________________________________________________________________________________________________________________________________________________
Name as Shown on Payment Card: ________________________________________________________________
Billing Address: (Required)
Street Address: _____________________________________________________________________________
City: __________________________________________________ State: __________ Zip: _________________
Phone Number of Card Holder: (Required) _________________________________________________________
Mailing Address (Required if different from billing address)
Street Address: _____________________________________________________________________________
City: __________________________________________________ State: _________ Zip: __________________
Phone Number of Card Holder: (Required) _________________________________________________________
Signature of Cardholder: _____________________________________________________ Date: __________________
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Type of Card: Visa MasterCard American Express
Visa or MasterCard #: _________________
- _________________ - _________________ - _________________
American Express #: _________________ - ________________________ - _________________
Expiration Date: ________________________
(MM/YY)
Note: The Board shreds this form after payment has been authorized by your credit card company
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