SOUTH DAKOTA BOARD OF TECHNICAL PROFESSIONS
2040 West Main Street, Suite 304, Rapid City, SD 57702-2447
Phone: 605-394-2510      Fax: 605-394-2509
Email:  dolsdbotp@state.sd.us

CREDIT CARD AUTHORIZATION FORM

This form is can be mailed, faxed or  e-mailed to our office.

Amount $ MasterCard Visa
Name of Applicant:
Name on Card:
Card Number:
Card Expires:
Month		 /
Year

 

For Office Use Only

                Reason:____________________________ 

                Receipt #:________________

                Need to run through  Authorize Net _______  Date:_________________