CGFNS credit card authorization
Credit Card Authorization Form
Sign and complete this form to authorize Apply Ready License Processing Inc. to transact, process and make a payment for
using the credit card information listed below.
By signing this form, you authorize Apply Ready to process your
application, prepare and accomplish
paperwork and make payment to
on your behalf using the credit card details you provide on this form. This is authorization for Apply Ready to transact on your behalf with
to use the credit card provided below, and does not provide authorization for any additional unrelated debits or credits to your account. Note: The amount charged to the credit card will be reflected as a charge from
Apply Ready on your billing statement.
(name on credit card), authorize Apply Ready License Processing Inc. to make payment to
on my behalf using my credit card account indicated below for
Type of Payment:
(Apply Ready MANILA)
Billing Address of Credit Card:
City, State, Zip:
[City, State, Zip]
Answer the following fields based on the
Indicates required field
City, Address, Zip:
CVV2 (3 OR 4 digit number on back of Visa/MC, 4 digits on front of AMEX):
I authorize APPLY READY LICENSE PROCESSING INC to transact & make payment to CGFNS on my behalf using the credit card indicated in this authorization form according to the terms outlined above. This payment authorization is for the services described above, for the amount indicated above only, and is valid for one time use only. I certify that I am an authorized user of this credit card and that I understand that the service charge will be from CGFNS and NOT Apply Ready and I will not dispute the payment with my credit card company; so long as the transaction corresponds to the terms indicated in this form.
Max file size: 20MB
Please attach your signature here...
CVS For New York
NCLEX LICENSE RENEWAL
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