SR-LV-034E (2017/01) Queen's Printer for Ontario, 2017 Disponible en franais

Credit Card Authorization Service Ontario

InstructionsIf you have any questions about the information collected on this form, please contact the Operations Manager, ServiceOntario Driver & Vehicle Contact Centre at 416 235-2999 or 1 800 387-3445 or visit www.serviceontario.ca. The personal information provided by you on this form is collected to assist with payment verification for the Ministry of Transportations driver, vehicle and carrier products and services, for which the Ministry is responsible under the Highway Traffic Act. Note: Under provincial legislation, a false statement from the applicant may result in a penalty.

Office Use Only Operator Number Office Number

Business Date (yyyy/mm/dd)

Fee Paid

Applicant's InformationName/Company/Dealer

AddressUnit/Apt/Suite Number Street Number Street Name PO Box Rural Route

Lot Number Concession Township City/Town

Province/State Postal Code/Zip Code Country

Daytime Telephone Numberext.

Alternate Telephone Number Email Address

Ontario Identification NumberPlease select and provide one (1) of the Ontario identification numbers below.

Driver's Licence (DL) Number Licence Plate Number

Registrant Identification Number (RIN) Dealer Number

Commercial Vehicle Operator's Registration (CVOR) Number National Safety Code (NSC) Number

Motor Vehicle Inspection Station (MVIS) Number Vehicle Identification Number (VIN)

If you do not have any of the Ontario identification numbers requested please select Not Available

Credit Card InformationName of the Credit Card CompanyName of Cardholder as it appears on the credit card

Visa Master CardName of the Signing Authority (If different than name of Cardholder)

Signature of Cardholder or Signing Authority Date (yyyy/mm/dd)

SR-LV-034E (2016/12) Queen's Printer for Ontario, 2016 Disponible en franais Medium Sensitivity when completed

Credit Card Number Card Expiration Date (mm/yy)

http://www.ontario.ca/welcome-serviceontario

Credit Card Authorization

SR-LV-034E (2017/01) Queen's Printer for Ontario, 2017

Disponible en franais

Credit Card Authorization

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Government of Ontario

Credit Card Authorization

Service Ontario

Instructions

Instructions.

If you have any questions about the information collected on this form, please contact the Operations Manager, ServiceOntario Driver & Vehicle Contact Centre at 416 235-2999 or 1 800 387-3445 or visit www.serviceontario.ca. The personal information provided by you on this form is collected to assist with payment verification for the Ministry of Transportations driver, vehicle and carrier products and services,

for which the Ministry is responsible under theHighway Traffic Act.

Note:Under provincial legislation, a false statement from the applicant may result in a penalty.

Office Use Only

Office use only.

Applicant's Information

Address

Ontario Identification Number

Pleaseselect andprovideone (1)of the Ontario identification numbers below.

If you do not have any of the Ontario identification numbers requested please select

Credit Card Information

Name of the Credit Card Company

SR-LV-034E (2016/12) Queen's Printer for Ontario, 2016

Disponible en franais

Medium Sensitivity when completed

8.0.1291.1.339988.308172

Credit Card Authorization Form

Credit Card Authorization Form

Print Form: Clear Form: TextField1: initFld: Office use only. Operator number.: Office use only. Office number.: Office use only. Business Date.: Office use only. Fee paid.: 0Applicant information. Name or Company or Dealer: Applicant information. Address. Unit/Apt/Suite Number.: Applicant information. Address. Street number.: Applicant information. Address. Street name.: Applicant information. Address. Post office box.: Applicant information. Address. Rural route.: Applicant information. Address. Lot number.: Applicant information. Address. Concession.: Applicant information. Address. Township.: Applicant information. Address. City or Town.: Applicant information. Address. Province or State.: Applicant information. Address. Postal code or Zip code.: Applicant information. Address. Country.: Applicant information. Alternate Telephone Number: Applicant information. Telephone number extension.: Applicant information. Email address.: driverlicenceNo: 0Ontario Identification Number. Driver's licence number.: licenceplateNo: 0Ontario Identification Number. Licence plate number. : rinNo: 0Ontario Identification Number. Registrant identification number. : dealerNo: 0Ontario Identification Number. Dealer number.: cvorNo: 0Ontario Identification Number. Commercial vehicle operator's registration number.: nscNo: 0Ontario Identification Number. National safety code number.: mvisNo: 0Ontario Identification Number. Motor vehicle inspection number.: vinNo: 0Ontario Identification Number. Vehicle identification number.: Ontario Identification Number. If you do not have any of the Ontario identification numbers requested please select. Not available.: 0Credit card information. Name of cardholder as it appears on the credit card.: Credit card information. Name of the credit card company. Visa.: Credit card information. Name of the credit card company. Master Card: Credit card information. Name of the signing authority. if different than name of cardholder.: Credit card information. Signature of cardholder or signing authority.: Credit card information. Date. Enter date in format: year: 4 digits, month: 2 digits, day: 2 digits. Or select date from the drop down calendar.: Credit card information. Credit card number: Credit card information. Card expiration date. Enter date in format: month: 2 digits, year: 2 digits. Or select date from the drop down calendar.: