Fax
Mail
Counter
Service Type:
Billing Address
City, State, Zip
Telephone
USE BLACK INK ONLY - DO NOT HIGHLIGHT
ePayment Checklist
(For Counter, Fax and Mail Requests)
Name as it Appears on the Account
Payment Authorization
Nevada Secretary of State ePayment Checklist
Revised: 1-5-15
I authorize the Secretary of State to bill an amount not to exceed the following to be charged to the above listed
account(s):
Not to Exceed Amount:
Authorized Signature
Entity Name/Order Reference:
Card Holder Information:
USD $
Order Processing Requested:
24-HOUR Expedite 2-HOUR Expedite 1-HOUR Expedite
Regular Processing
(Expedite Processing Requires Additional Fees)
Order Information (required)
MasterCard
VISA
Customer Credit Card Number:
V CODE*
Year
Month
Discover
American Express
* 3-digit number found on the far right of the backside of VISA, MasterCard and Discover cards
4-digit number found on the front right side of American Express card.
Card Type:
NOTICE: For security and verification purposes, all credit card payments must include the 3 or 4-digit CVV2 code
(VCode) number located on the credit card. Failure to include this code will result in the rejection of your filing or service
request.
Credit Card Expiration Date:
Amount to Charge Card:
Payment by Card (card holder name and billing address required below)
USD $
BARBARA K. CEGAVSKE
Secretary of State
202 North Carson Street
Carson City, Nevada 89701-4201
(775) 684-5708
Website: www.nvsos.gov
X
