Credit Card Payment Authorization Form
Please obtain the following pertinent information
*CARD NUMBER *EXPIRATION DATE MO. YR
Verification Code (VCODE) - A 3-4 digit, non-embossed number found on card signature panel or near embossed number on front.
*Name on credit card
Your name as it appears on the card and the name of your organization (if applicable)
*Zip code Telephone No.
*Amount: * Signature:
Profession: What is the payment for?
LSWA, LCSW, LSW E.g.: Application, renewal, training, etc.
* PLEASE NOTE - WE WILL NOT PROCESS YOUR REQUEST IF THE REQUIRED FIELDS ARE BLANK
If payment is for an application or renewal, please provide the following additional information:
Name(s) and license #(s)(if applicable) to apply payment to: