creditcards

Credit Card Payment Form

Credit Cards

Please fill out this form, print it, sign it and mail or fax it to the Liquor Commission
Date:
Trade Name:
Licensee Number:
Amount to Charge:
Name:	(as it appears on card)
Credit Card Type:
Credit Card Number:
Expiration Date:
Signature:	(I agree to pay above amount according to card issuer agreement)
Payment Type:	Pre-pay Pending Orders Invoice

Fax this form to:	or Mail this form to:
(603) 271-2375	State of New Hamsphire Liquor Commission P.O. Box 503 Concord, N.H. 03302-0503
Any questions should be forwarded to the Accounts Receivable Department at 230-7053.

URL: http://outlet/www/creditcards.shtml Updated: 12/01/10 09:24:25

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