USVI Public Records

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One (1) Time Credit Card Payment Authorization Sign and complete this form to authorize the “The Government of the VI” (Virgin Islands Department of Health) to make a one-time charge to your credit card as listed below. By signing this form (electronically or otherwise), you give The Government of the VI” (Virgin Islands Department of Health) permission to debit your account for the amount indicated below. This permission is for a single transaction only and does not provide authorization for any additional unrelated debits or credits. I __________________________________ authorize _ Government of the VI to charge the (Cardholder’s Full Name) (Merchant’s Name) credit card account indicated below the amount of US $ Amount Payment for ____________________________ for _____________________ License #_________ First, Middle, Last Name (Licensee/Entity) Credential Application, Registration, If Applicable License Renewal, CON, Verification, Billing Information Copies, etc. Billing Address: _____________________________ Cell phone # _________________________ City, State, Zip: _______________________ Email: ______________________________ Card Details “If you are not the Applicant or License holder please include a Copy of a Government Issued ID.” ☐ Visa ☐ MasterCard Cardholder’s Name as it Appears on Card ____________________________________ Credit Card Number# _______________________________ Expiration Date ____ / _______ CVV _________ Zip Code _________ I authorize the Government of the VI (Department of Health) to charge the credit card indicated in this authorization form according to the terms outlined above. This payment authorization is for the services indicated and, in the amount indicated above only and is valid for one (1) time use only. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company so long as the transaction corresponds to the terms indicated in this form. Cardholder Original Signature Date