New York State
Department of State
Division of Licensing Services
P.O. Box 22001
Albany, NY 12201-2001
Customer Service: (518) 474-4429
www.dos.ny.gov
Credit Card Authorization
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 / P.O. 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-a (Rev. 09/15)
