VP 205 Payment Card Authorization

555 Wright Way Carson City, NV 89711 Reno/Sparks/Carson City (775) 684-4DMV (4368) Las Vegas area (702) 486-4DMV (4368) Rural Nevada or Out of State (877) 368-7828 www.dmvnv.com Select ATM/Debit * Payment Amount $ Payment Type: Credit Master Card Visa Discover Card Debit or Credit Card Number (one number per box) - - - Please Print or Type Cardholder Information Expiration Date Printed Name / Mailing Address Month Year Street / P.O. Box City State Zip Code Plate / Driver Lic. / Motor Carrier Number Telephone ( ) Authorized Signature Date VP205 (11/11) *I understand and agree that by checking “ATM/Debit” I am authorizing the DMV to debit my account for the amount specified above. Further, I understand and agree that

if the ATM/Debit transaction fails or is declined, I am authorizing the DMV to complete the transaction as a credit card charge, if possible....

Website: www.dmvnv.com | Filesize: 73kb
No of Page(s): 1
Download VP 205 Payment Card Authorization.pdf