TO PAY BY CREDIT CARD, PLEASE COMPLETE THE …

TO PAY BY CREDIT CARD, PLEASE COMPLETE THE INFORMATION
BELOW AND RETURN WITH YOUR PAPERWORK (BY EMAIL, FAX OR MAIL).
Payment Amount: ____________________________________________
Employer/Company Name: ______________________________________
Your name as it appears on your credit card:
__________________________________________________________
( Visa ( Mastercard ( Discover ( American Express
Credit Card Number: __________________________________________
Credit Card Expiration Date: ____________________________________
Address to which your credit card bill is mailed:
Address: __________________________________________________
City: _________________________ State: ______ Zip: ____________
Phone:________________________
Cardholder’s Signature: _______________________________________
NOTE: There is a $6 convenience fee placed
on every credit card transaction.
IF YOU WOULD LIKE A RECEIPT FAXED OR EMAILED TO YOU:
_____________________________________________________
Kentucky Legislative Ethics Commission
22 Mill Creek Park
Frankfort, KY 40601
Phone 502-573-2863
Fax 502-573-2929
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