Page 249 - AG 7-2011 Revised 2016

ST ATE OF CALIFORNIA
D EPARTMENT OF PESTICIDE REGULATION

1001 I STREET
SACR""'1ENTO,CA95814-2828

�b site:http://www.cdpr.ca.gov
OPR • 105(REV. 101ll3)

Page 1 of1

VISA I MASTERCARD 1RANSAC110N

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INSTRUCTIONS:

1. For conducting transactions using \11SA or MasterCard only. No other cards are accepted.

2. Complete ALL car dholder information.

3. If you have any questions, please call the Licensing and Certification Program at (916) 445-4038.

4. Mail your com pleted application with this form to the appropriate address below:

Licensees: Continuing Education Sponsors:

ATIN: Cashier Cashier
Department of Pesticide Regulation ATIN CE

P.O. Box 4015 Depar tment of Pesticide Regulation
Sacramento, CA 95812-4015 P.O. Box 4015
Sacramento, CA95812-4015

5. DO NOTFAX this form to DPR

N""'1E OF CAROHOLOE R(N;MEAPPEARING ON THE BANK CARO) n nMost. .CHECKONE TOOA'l'S OATE
1/ISA
BANKCARO card
NUMBER (16 OIGITS)
BANKCARO EXPIRATION OATE TOTAL.AMOUNT OF PA'IMENT

TELEPHONENUMBER
()

SIGNATURE O F CARDHOLDER (NAME APPEARING ON THE BANK CARD)
FOR PAYMENT OF:

NAME OF LICENSEE OR SPONSOR
MAILING ADDRESS (Street or P.O. Box Number)
(City, State, and ZIP Code)

(DEPARTMENT USE ONLY)- ENTERED ONPOS BY: TODAYS DATE OATEMAJLEO BY