#3071 (Rev. 11/19)
Committed to Equal Opportunity in Employment and Licensing
Wisconsin Department of Safety and Professional Services
DIVISION OF PROFESSIONAL CREDENTIAL PROCESSING
FAX PAYMENT FORM
Fax completed form and required documents to 608-251-3036
(Please allow 7 to 10 business days for processing.)
NOTE: If paying application fee and/or expedited processing fee, application MUST be faxed with this form.
CUSTOMER INFORMATION
Name of Applicant/Credential Holder:
A
pplication/Credential Number:
(if applicable)
Pro
fession(s):
REQUIRED PAYMENT INFORMATION: Your request will not be processed unless all information below is completed.
If paying application fee, application MUST be faxed with this form. Mark the appropriate box(es) to indicate type of payment.
Initial Credential Fee
Exam/Retake
Renewal Fee/Late Fee
CIB Fee
Re-Registration
Temporary Permit
Predetermination Other: (please list)
Nam
e of Card Holder:
Email Address:
Daytime Phone Number:
- -
A
re you requesting an expedited process?
Yes No If yes, include an additional $10.00 fee for this service.
Expedited processing only applies to the Initial Credential, Re-Registration and Temporary Permit fees and must be includedwith the
application and all fees.
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:
$
Card
holder’s Address:
Street
City State Zip Code
Credit Card Number: Expiration Date:
-
-
-
/
Security Code:
I understand b
si
nin
below, I authorize the State of Wisconsin Department of Safet
and Professional Services to charge my credit card for the above amount and a 2%
convenience fee assessed at the time of processin
.
Cardholder’s Si
nature:
DSPS uses
Ri
htFax to ensure sa
e and secure transmission o
our pa
ment in
ormation
For Receipting Purposes
(Print and Sign Form)
