Free None - Wisconsin

DEPARTMENT OF HEALTH AND FAMILY SERVICES Division of Public Health DPH 44029 (04/05)

STATE OF WISCONSIN Bureau of Environmental & Occupational Health Asbestos & Lead Certification Unit HFS 159/163, Wis. Adm. Code

CREDIT CARD PAYMENT
Notice to Applicant: The credit card information on this form will only be used for the processing of your fee payment. After the credit card transaction has been successfully completed, this form will be shredded. Certification fees may be paid by Visa or Master Card. Complete the information below and attach this form to your application. (A separate form is required for each application.) APPLICANT INFORMATION Applicant's Name (first/last or company): _____________________________________________________________________ Applicant's DHFS Certification Number: ______________________________ Amount authorized: $____________________

CREDIT CARD HOLDER INFORMATION Name, as on the credit card: ______________________________________________________________________________ If corporate credit card, company name: _____________________________________________________________________ Cardholder Address: ______________________________________________________________________________________________ Telephone Number (for questions): ____________________________________________________________________________ E-mail (Transaction confirmation will be e-mailed): ________________________________________________________________ Credit Card Number: ____________________________________________________ Expiration Date ___________________

Authorized Credit Card Holder Signature ____________________________________________ Date ____________________