1. Print form Clear form TC-894
Recurring Credit Card Charge Authorization Rev. 5/04
Company name Dealer number
Card holder's name Card holder's telephone number
Card holder's email address
Billing address
City State ZIP code
Card type (Check one) DMV accounts receivable number
American Express
Visa Discover
MasterCard
Card number Expiration date (mo./yr.)
Date this authorization expires
This authorization will expire on the expiration date for this credit card, unless you want to terminate
this authorization sooner. If you want to terminate this authorization sooner, provide a date for expiration.
I authorize the Division of Motor Vehicles to automatically charge my credit card account, shown above, for the legal payable amount
allowed for services provided. I understand that any payments are based on the current legal price information available, during the
registration process.
My right to use this service is subject to any limits established by my credit card issuer. It is my responsibility to update the credit card
information that is used to pay for this service. I understand that I may notify the Division of Motor Vehicles by written request at anytime to
terminate this authorization.
The Division of Motor Vehicles reserves the right to charge this account without requiring the customer's signed authorization for each
transaction. Also, the Division of Motor Vehicles reserves the right to terminate this authorization agreement at anytime.
Card holder's signature (read statement above) Today's date
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