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