Fillable Credit Card Payment Authorization Form (Oklahoma)

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Credit Card Payment Authorization Form (Oklahoma)

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The Credit Card Payment Authorization Form (Oklahoma) form is 1 page long and contains:

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  • 4 check-boxes
  • 19 other fields

Country of origin: US
File type: PDF

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Credit Card Payment Authorization Form
Please obtain the following pertinent information
*CARD NUMBER *EXPIRATION DATE MO. YR
*VCODE
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)
*Billing address
*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:
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Credit Card Payment Authorization Form (Oklahoma)

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Completed 23 April 2021

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