Fillable Wisconsin Department of Safety and Professional Services (Wisconsin)

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Wisconsin Department of Safety and Professional Services (Wisconsin)

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#3073 (Rev. 7/16)
Committed to Equal Opportunity in Employment and Licensing
Wisconsin Department of Safety and Professional Services
DIVISION OF PROFESSIONAL CREDENTIAL PROCESSING
TRADES FAX PAYMENT FORM
Fax completed form and required documents to 608-267-0592
NOTE: Submission of this form will not expedite the processing of your application for credential or start the initial process, all items
are processed in the order they are received. Once all required materials are received, the Department will make a determination on your
application for credential within 21 calendar days per Wis. Admin. Code § SPS 305.04(1).
CUSTOMER INFORMATION
Name of Credential Holder:
License/Customer ID #:
Telephone Number:
- -
Profession(s):
Email Address:
REQUIRED PAYMENT INFORMATION
Same as Customer Information Above
Mark the appropritate box(es) to indicate type of payment.
Initial Credential Fee
Application Fee
Renewal Fee/Late Fee
Other: (please list)
Name of Card Holder:
Cardholder’s Telephone Number:
- -
Cardholder’s Address:
(Street)
(City)
(State)
(Zip Code)
Please Note: For all credit and debit card transactions, a 2% convenience fee will be assessed and will appear as a separate charge on your statement. This
fee is non-refundable.
Total Amount to Charge: $
Credit Card Number:
Expiration Date:
- - -
/
Security Code:
I understand by signing below, I authorize the State of Wisconsin Department of Safety
and Professional Services to charge my credit card for the above amount and a 2%
convenience fee assessed at the time of processing.
Cardholder’s Signature:
DSPS uses RightFax to ensure safe and secure transmission of your payment information
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Wisconsin Department of Safety and Professional Services (Wisconsin)

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Completed 17 February 2022

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