Credit Card Payment Authorization Form - Oklahoma
Credit Card Payment Authorization Form
Please obtain the following pertinent information
*CARD NUMBER
*EXPIRATION DATE MO. YR
*VCODE Verification Code (VCODE) - A 3-4 digit, non-embossed number found on card signature panel or near embossed number on front.
*Name on credit card
Your name as it appears on the card and the name of your organization (if applicable)
*Billing address *Zip code
Telephone No.
*Amount:
* Signature:
Profession:
LSWA, LCSW, LSW
What is the payment for? E.g.: Application, renewal, training, etc.
* PLEASE NOTE - WE WILL NOT PROCESS YOUR REQUEST IF THE REQUIRED FIELDS ARE BLANK
If payment is for an application or renewal, please provide the following additional information: Name(s) and license #(s)(if applicable) to apply payment to: 1. 2. 3. 4. 5.
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