Department of the Secretary of State
Bureau of Corporations, Elections and Commissions
If you wish to pay for filing fees or other services offered by this Bureau with your credit card, please
complete the following credit card payment voucher and submit it with your request.
Check the appropriate box:
***Office Use Only***
Credit Amount _____________________________
Check/Cash Amount_________________________
Work Request #_____________________________
Credit Card No.: _______________________________________________________
Expiration Date: ____________________ (mm/yy)
Name (as it appears on card): _______________________________________________________
(Please use the address to which your credit card bills are sent)
Address (No. and Street): _______________________________________________________
Address (Apt. or Suite): _______________________________________________________
Town: _____________________________
State: ____________________
Zip Code: ____________________
________________________________________________________ ________________
Cardholder’s Signature Date
Daytime Telephone Number: _________________________________