Fillable PAYMENT AUTHORIZATION FORM (State of Nevada, Department of Information Technology)

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PAYMENT AUTHORIZATION FORM (State of Nevada, Department of Information Technology)

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The PAYMENT AUTHORIZATION FORM (State of Nevada, Department of Information Technology) form is 1 page long and contains:

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  • 3 check-boxes
  • 15 other fields

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File type: PDF

U.S.A. forms for State of Nevada, Department of Information Technology

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

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555 Wright Way
Carson City, NV 89711
Reno/Sparks/Carson City (775) 684-4DMV (4368)
Las Vegas area (702) 486-4DMV (4368)
dmvnv.com
PAYMENT AUTHORIZATION FORM
DO NOT EMAIL FORM
Debit or Credit Card Number
(one number per box)
-
-
-
Expiration Date
Payment Type:
Master Card
Visa
Discover Card
Month
Year
-----------------------------------------------------------------------------------------------------------------------
Cardholder Information
Printed Name
Payment
Cardholder Billing Address
Print your name as it appears on your card
Pursuant to NRS 353.1467, credit card
payments of $10,000 or more are not permitted
and cannot be split between multiple payments
and/or card types.
Street / P.O. Box
City
State
Zip Code
Plate/Driver Lic./Bus. Lic./Records/MC
Number of the transaction being processed.
Telephone
Authorized Signature
Date
ADM-205 (Rev. 6/2019)
By signing this form, you give us permission to debit your account for the amount
indicated on or after the indicated date.
I authoriz
e the DMV to charge the credit/debit card indicated in this authorization form
according to the terms outlined above. This payment authorization is 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/debit card and that I will not dispute the payment with my credit/debit
card company so long as the transaction corresponds to the terms indicated in the form.
Do not email this authorization form. E-mail is NOT a secure form of transmittal to protect
your card information.
“
Super Tran ID
Office Use Only
Last four of Card Number
Technician Number
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PAYMENT AUTHORIZATION FORM (State of Nevada, Department of Information Technology)

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Completed 4 March 2021

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