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Credit Card Payment Form
Source: www.ncpublicschools.org
File Size: 55.16 KB
Category: Business and Economy
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Short Description: *In the signature box on the back of the card, you should see either the entire 16-digit credit card number or just the last four digits followed by a ...
Content Inside: Licensure Section Credit Card Payment Authorization Licensure Applicant Information
Last Name ___________________ First Name ________________________ Middle Name _________________ Maiden Name ______________________ Social Security Number
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Cardholder Information
Name on the Card: ___________________________________________
Mastercard Visa
Credit Card Number
--- Expiration date: / Card Security Code*
I authorize the Licensure Section of the NC Department of Public Instruction to charge
*In the signature box on the back of the card, you should see either the entire 16-digit credit card number or just the last four digits followed by a 3-digit code. This 3-digit code is your Card Security Code.
the processing fee for licensing ( to my credit card.
$30; $55; $85; $______ (other amount))
Signature _____________________________________ Date ____________
Licensure Section 6365 Mail Service Center Raleigh, North Carolina 27699-6365 www.ncpublicschools.org/licensure/
