Page 265 - 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

INSTRUCTIONS:

1. For conducting transactions using VISA or MasterCard only. No other cards are accepted.

2. Complete ALL cardholder information.

3. If you have any questions, please call the Licensing and Certification Program at (916) 4454- 038.

4. Mail your completed application with this form to the appropriate add ress below:

Licensees: Continuing Education Sponsors:

ATIN: Cashier Cashier
Department of Pes ticide Regulation ATIN CE

P.O. Box 4015 Department of Pes ticide Regulation
Sacramento, CA 95812-4015 P.O. Box 4015
Sacramento, CA 95812-4015

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 1O7A3TEMAJLEO BY
259