Credit Card Debit Card Authorization {DOS-1515-f}

Attach this form to your document, certificate or other written request. The Name of the Corporation or Business Entity to Which This Request Applies is: Check Box for Requested Service: Fill in Fee or Amount: FILING OF DOCUMENT OR CERTIFICATE (Consult appropriate fee schedule for fee) $ Check the appropriate box: Routine Processing: No additional fee Expedited Processing: 24-Hour Additional $25 fee Same Day Additional $75 fee 2-Hour Additional $150 fee $ CERTIFIED COPY (The fee for each certified copy is $10) $ Check the appropriate box: Routine Processing: No additional fee Expedited Processing: 24-Hour Additional $25 fee Same Day Additional $75 fee 2-Hour Additional $150 fee $ PLAIN COPY (The fee for each plain copy is $5) $ Check the appropriate box: Routine Processing: No additional fee Expedited Processing: 24-Hour Additional $25 fee Same Day Additional $75 fee 2-Hour Additional $150 fee $ CERTIFICATE OF STATUS (Certificates of Good Standing, etc. The fee for each certificate is $25.) $ Check the appropriate box: Routine Processing: No additional fee Expedited Processing: 24-Hour Additional $25 fee Same Day Additional $75 fee 2-Hour Additional $150 fee $ SERVICE OF PROCESS (Must be served in person at the above address) $ BIENNIAL / FIVE YEAR STATEMENT $ OTHER $ DEPOSIT TO DRAWDOWN : Account Name: Account Number: $ TOTAL (Total Amount Due) $ Same Day expedited service requests must be received by 12 noon on regular business days. 2-hour expedited service requests must be received by 2:30 p.m. on regular business days. Expedited processing fees are charged even if a document, certificate or other request is rejected as deficient. Credit/Debit Card Information: MasterCard Visa American Express TYPE OR PRINT CLEARLY Card Number: Expiration Date (Month/Year): Name as it Appears on Card: City: State: Zip Code: Fax Number: Date: If the name on the card is in the name of a corporation or DOS-1515-f (Rev. 04/16) Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com