The Miami Tribe Tax Commission

P.O. Box 1326

Miami, OK 74355

(918) 542-1445

Fax:  (918) 542-7260

www.miamination.com

CREDIT CARD AUTHORIZATION

I, ______________________________, authorize the Miami Tribe Tax Commission to charge my credit/debit card for the following:

• Fees associated with the registration or registration renewal for the following my vehicle(s).
• Other (Please Specify): _________________________________________________________

Charge Type:    Credit (  )          Debit (  )

Card Type:        Visa (  )            MasterCard (  )

Credit Card Number:     _____________________________________

V-Code:  ___________________                    Expiration Date:  _______________________

                           (on the reverse of card) (month/year)

Cardholder’s Name:  __________________________________________

                                                                                          (please print)

______________________________________________                __________________

Cardholder’s Signature                                                              Date

Billing Address:  (Where credit card statements are mailed)

________________________________________________

________________________________________________

________________________________________________

Mailing Address:  (If different from billing address)

________________________________________________

________________________________________________

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