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AUTHORIZATION OF CREDIT CARD PAYMENT

Fees owed to this Department may be paid by the use of a credit card.  If you wish to pay your fee(s) with your credit card, please complete this form and send it with your application.  Payment through credit cards will not be processed without this authorization form.

Business Name:
(Applicant fees being paid for)
Mailing Address:
City: State: Zip Code:
County: Telephone # : (         ) _________ - _____________
Name of Cardholder:
(If other than applicant)
Mailing Address:
(If other than applicant)
City: State: Zip Code:
County: Telephone # : (         ) _________ - _____________
I authorize the State of Maine, Department of Professional and Financial Regulation, Bureau of
Consumer Credit Protection to charge my:
[] Visa[] Mastercard _________________________________
Card Number
Expiration Date:________/________/________In the amount of: $ _____________________
Signature: ___________________________________Date: ________/________/________