Fillable Method of Payment DIVISION OF CONSUMER EQUITABILITY Public (State of Nevada, Department of Information Technology)

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Method of Payment DIVISION OF CONSUMER EQUITABILITY Public (State of Nevada, Department of Information Technology)

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BROWSE STATE OF NEVADA, DEPARTMENT OF INFORMATION TECHNOLOGY (NV) FORMS

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DIVISION OF CONSUMER EQUITABILITY
Public Weighmaster Program
2150 Frazer Avenue Sparks, NV 89431
Phone: (775) 353-3782 Fax: (775) 353-3798
Email: pwmreg@agri.nv.gov Web: agri.nv.gov/PWM
Method of Payment
Business Name: ______________________________________________ Invoice # ______________________
Payments MUST Include completed application information
Check here ONLY if payment and application information will be mailed separately.
Please note: Application and payment will not be processed until both has been received.
Check or Money Order Payable to:
NEVADA DEPARTMENT OF AGRICULTURE
2150 Frazer Avenue
Sparks, NV 89431
Credit Card:
Payment Type: Master Card Visa AMEX Discover Card
Payment Amount: $ _____________________________________________________
Name as it appears on Card: _________________________________________________________________
Email: ____________________________________________________________________________________
Authorized Signature: __________________________________________ Date: _______________________
Credit Card #:
- - -
Expiration Date: / Card Verification Value (CVV2):
*Credit Card information is not retained by the Nevada Department of Agriculture for future payments.
Billing Code: 4551-3616
WM-PWM-05
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Method of Payment DIVISION OF CONSUMER EQUITABILITY Public (State of Nevada, Department of Information Technology)

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Completed 10 March 2021

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