Free Form - Nevada


File Size: 301.0 kB
Pages: 1
File Format: PDF
State: Nevada
Category: Secretary of State
Word Count: 254 Words, 1,672 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.sos.state.nv.us/business/forms/omni/ePaymentChecklist.pdf

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ROSS MILLER Secretary of State 202 North Carson Street Carson City, Nevada 89701-4201 (775) 684 5708 Website: www.nvsos.gov

ePayment Checklist
(For Counter, Fax and Mail Requests)
USE BLACK INK ONLY - DO NOT HIGHLIGHT

Service Type:

Counter

Mail

Fax (Expedite Processing Requires Additional Fees)

Order Processing Requested: Regular Processing

24-HOUR Expedite

2-HOUR Expedite

1-HOUR Expedite

Payment by Electronic Check
Account Type; Checking Savings Account Number: Routing Number:

(account holder name and address required below)

Amount of Electronic Check:

USD $

Payment by Card
Card Type: VISA

(card holder name and billing address required below)
MasterCard Discover American Express V CODE*

Customer Credit Card Number:

* 3-digit number found on the far right of the backside of VISA, MasterCard and Discover cards 4-digit number found on the front right side of American Express card.

NOTICE: For security and verification purposes, all credit card payments must include the 3 or 4-digit CVV2 code (VCode) number located on the credit card. Failure to include this code will result in the rejection of your filing or service request. Credit Card Expiration Date: Month Year

Amount to Charge Card:

USD $

Order Information (required)
Entity Name/Order Reference: Account/Card Holder Information:
Name as it Appears on the Account Billing Address City, State, Zip Telephone

Payment Authorization
I authorize the Secretary of State to bill an amount not to exceed the following to be charged to the above listed account(s):

X
Authorized Signature Reset

Not to Exceed Amount:

USD $

Nevada Secretary of State ePayment Checklist Revised: 2-9-09