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: ________/_________/_______