1141 State Street, Suite 200 – PO Box 1268 – Bowling Green, KY 42102-1268
Bowling Green – Warren County
CONTRACTORS LICENSING BOARD
Bob Appling Office: (270)781-3530 / Fax:(270)781-3481 Holly Warren
Executive Director www.bgky.org/contractorslicensing Office Manager
CREDIT CARD AUTHORIZATION FORM
Please circle the appropriate card: Mastercard Visa Discover American Express
Company name: _____________________________________________________
Cardholder Name: _____________________________________________________
Billing Address: _____________________________________________________
City, State, Zip: _____________________________________________________
Phone: _____________________________________________________
Fax: _____________________________________________________
Cell: _____________________________________________________
Credit Card number: ____________________________________________________
Expiration Date: _____________________________________________________
CVV2 Code (3 digit code on back of card):__________________________________
License Fee: __________________________________
Handling Fee: (add $4.00 for Specialty)
or
(add $10.00 for General ) __________________________________
Total: __________________________________
I AGREE TO PAY THE ABOVE TOTAL AMOUNT ACCORDING TO THE CARD
ISSUER AGREEMENT (MERCHANT AGREEMENT IF CREDIT VOUCHER).
__________________________________________ ________________________
CARDHOLDERS SIGNATURE DATE
