Form Dos-1515 - Credit Card Authorization
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1NYS Department of State
41 State Street
DIVISION OF CORPORATIONS
Credit Card Authorization
Albany, NY 12231-0001
The Department of State’s Division of Corporations accepts MasterCard, Visa and American Express for payment of certain fees. To pay the fee for this
transaction using a credit or debit card, simply complete and sign this page and attach it to your written request to process a document or your request
for other services. Please consult the appropriate fee schedule for specific filing fees.
Name of Entity To Which This Service Request Applies:
Check Box for Request Service:
Fill in Fee or Amount:
FILING OF DOCUMENTS AND CERTIFICATES
$
G
*Expedited Service:
G 24 hour-$25
G Same day-$75 (must be received prior to 2.01 pm)
G 2 hour-$150
$
G
CERTIFIED COPY
($10 each)
$
*Expedited Service:
G 24 hour-$25
G Same day-$75 (must be received prior to 2.01 pm)
G 2 hour-$150
$
G
PLAIN COPY
($5 each)
$
*Expedited Service:
G 24 hour-$25
G Same day-$75 (must be received prior to 2.01 pm)
G 2 hour-$150
$
G
CERTIFICATE UNDER SEAL
(Certificates of Good Standing, etc. ($25 each)
$
*Expedited Service: G 24 hour-$25
G Same day-$75 (must be received prior to 2.01 pm)
G 2 hour-$150
$
G
SERVICE OF PROCESS
(Must be served in person at the above address)
$
G
BIENNIAL/FIVE YEAR STATEMENT
$
G
DEPOSIT TO DRAWDOWN
$
If applicable: service company must indicate name and number:
TOTAL (Total Amount due)
$
*Expedited Service fees are non-refundable. Expedited Service fees will not be refunded even if a filing is rejected.
Please charge to the following credit card:
Q
Q
Q
MasterCard
Visa
American Express
Expiration Date: (Month)
(Year)
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Credit card number:
NAME AS IT APPEARS ON THE CREDIT CARD (PRINT)
CARDHOLDER’S BILLING ADDRESS AS LISTED WITH CREDIT CARD COMPANY
CITY
STATE
ZIP CODE+4
Cardholder’s Signature
Date
If the name on the credit card is in the name of a corporation or other business entity, please print the signer’s name:
OPTIONAL:
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Daytime telephone number:
Fax telephone number:
Please note, omission of information may cause delay in the processing of your request.
F O R
O F F I C E
U S E
O N L Y
AUTHORIZATION NO.
FILM NUMBER
CASH NUMBER
DOCUMENT IDENTIFICATION NUMBER
DATE
CORP. ID NUMBER
REQUEST NUMBER
DOS-1515 (Rev. 12/04)
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Parent category: Financial