Division of Plant Industry | 10B Airline Dr. Albany, NY 12235 | (518) 457-2087 |
www.agriculture.ny.gov
RICHARD A.BALL
Commissioner
One Time Credit Card Payment Authorization Form
DO NOT FAX THIS FORM
Sign and complete this form to authorize the NYS Department of Agriculture and Markets to make a
onetime debit to your credit card listed below. Please mail to the address below.
By signing this form, you give us permission to debit your account for the amount indicated on or
after the indicated date. This is permission for a single transaction only and does not provide
authorization for any additional unrelated debits or credits to your account.
Please complete the information below:
I, , authorize the NYS Department of Agriculture and Markets to charge my
credit card account indicated below for $ . This payment is for : NYS Hemp Licensing Program
Account Type Visa MasterCard AMEX Discover
Cardholder Name
Account Number
Expiration Date
CVV2 (3-digit number on back of Visa/MC, 4 digits on front of AMEX)
FOR OFFICE USE ONLY
Estab No.
License No.
Receipt No.
Validation No.
I authorize the NYS Department of Agriculture and Markets to charge the credit card indicated in this
authorization form according to the terms outlined above. This payment authorization is for the Industrial
Hemp Program, for the amount indicated above only, and is valid for one time use only. I certify that I am an
authorized user of this credit card.
SIGNATURE DATE
Billing Address:
City: State: Zip:
Business Name:
Name: Phone:
Address:
City: State: Zip: County:
Email:
