Free Credit Card Authorization Form - New York

NYS Department of State DIVISION OF CORPORATIONS

Credit Card/Debit Card Authorization
Attach this form to your document or written request.

One Commerce Plaza, 99 Washington Ave. Albany, NY 12231-0001 www.dos.state.ny.us

The Department of State's Division of Corporations accepts MasterCard, Visa and American Express for payment of certain fees.

The Name of Corporation or Other Business Entity To Which This Service Request Applies is:
Check Box for Requested Service: FILING OF DOCUMENTS AND CERTIFICATES
(Please consult the appropriate fee schedule for specific filing fees) *Optional Expedited Service: 24 hour-$25 Same day-$75 2 hour-$150

Fill in Fee or Amount: $ $ $ $ $ $ $
2 hour-$150

CERTIFIED COPY ($10 each)
*Optional Expedited Service: 24 hour-$25 Same day-$75 2 hour-$150

PLAIN COPY ($5 each)
*Optional Expedited Service: 24 hour-$25 Same day-$75 2 hour-$150

CERTIFICATE UNDER SEAL (Certificates of Good Standing, etc. ($25 each)
*Optional Expedited Service: 24 hour-$25 Same day-$75

$ $ $ $ $

SERVICE OF PROCESS (Must be served in person at the above address) BIENNIAL/FIVE YEAR STATEMENT OTHER DEPOSIT TO DRAWDOWN
Account Name: Account Number:

TOTAL (Total Amount due)$

* Same day expedited service requests must be received by 12 noon. 2 hour expedited service requests must be received by 2:30 p.m.
Expedited service fees are non-refundable and will not be refunded if a filing is rejected.

MasterCard
Card Number:

Visa

American Express

Expiration Date: (Month and Year) Name as it Appears on the Credit Card or Debit Card (Print)

Cardholder's Billing Address as Listed with Credit Card or Debit Card Company

City
Cardholder's Signature

State
Date

Zip Code+4

If the name on the credit card or debit card is in the name of a corporation or other business entity, please print the signer's name:

Daytime telephone number:

Fax number:

DOS-1515 (Rev. 02/09)