Notary Credit Card Authorization (Fillable)
Notaries Public Division • Credit Card Authorization Revised 4/ 2026 GOVERNMENT OF THE VIRGIN ISLANDS OF THE UNITED STATES OFFICE OF THE LIEUTENANT GOVERNOR NOTARIES PUBLIC DIVISION 5049 Kongens Gade | St. Thomas, Virgin Islands 00802 NOTARY CREDIT CARD AUTHORIZATION FORM Required: Include a legible copy of the cardholder’s government-issued photo identification (for example, a driver’s license or passport). Please print clearly, sign, and return this form by postal mail to the address above. CARDHOLDER INFORMATION Cardholder Name Date ____ / ____ / ______ Email Address Phone Number 1 (____) _____-_______ Billing Address City / State / ZIP PAYMENT INFORMATION Card Type ☐Mastercard ☐ Visa ☐ATH /ATM Amount Authorized $ Card Number _____ - _____ - _____ - _____ Expiration Date ____ / ______ Security Code (CVV) (3-digit code located on the back of the credit card) _____________ Payment Purpose Notary fee(s) ☐ Apostille service(s)☐ CARDHOLDER AUTHORIZATION I authorize the Office of the Lieutenant Governor, Notaries Public Division, to charge the amount shown above to the payment card iden …
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Notaries Public Division • Credit Card Authorization Revised 4/ 2026 GOVERNMENT OF THE VIRGIN ISLANDS OF THE UNITED STATES OFFICE OF THE LIEUTENANT GOVERNOR NOTARIES PUBLIC DIVISION 5049 Kongens Gade | St. Thomas, Virgin Islands 00802 NOTARY CREDIT CARD AUTHORIZATION FORM Required: Include a legible copy of the cardholder’s government-issued photo identification (for example, a driver’s license or passport). Please print clearly, sign, and return this form by postal mail to the address above. CARDHOLDER INFORMATION Cardholder Name Date ____ / ____ / ______ Email Address Phone Number 1 (____) _____-_______ Billing Address City / State / ZIP PAYMENT INFORMATION Card Type ☐Mastercard ☐ Visa ☐ATH /ATM Amount Authorized $ Card Number _____ - _____ - _____ - _____ Expiration Date ____ / ______ Security Code (CVV) (3-digit code located on the back of the credit card) _____________ Payment Purpose Notary fee(s) ☐ Apostille service(s)☐ CARDHOLDER AUTHORIZATION I authorize the Office of the Lieutenant Governor, Notaries Public Division, to charge the amount shown above to the payment card identified on this form. I certify that I am the authorized cardholder and that the information provided is accurate. Cardholder Printed Name Signature Date Signed ____ / ____ / ______ SECURITY NOTICE: Do not send this completed form by unencrypted email. For your protection, the Division should retain and dispose of payment-card information in accordance with applicable records and security procedures. SIGN