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ADM205 Payment Authorization Form - dmvnv.com

555 Wright Way Carson City, NV 89711 Reno/Carson City (775) 684-4368 Las Vegas area (702) 486-4368 ADM-205 (Revised 04/2022) Payment Authorization FORM DO NOT EMAIL FORM Debit or Credit card Number (One number per box) - - - Expiration Date Cardholder Information Printed Name: Payment Amount (Required): Print your name as it appears on your card Pursuant to NRS , credit card payments of $10,000 or more are not permitted and cannot be split between multiple payments and/or card typesCardholder Billing Address: Street Address or Box City State Zip Code License Plate # / Driver License # / Business License # / Records# / Motor Carrier # of the transaction being processed: Telephone: Authorized Signature: Date: By signing this form, you give the DMV permission to debit your account for the Payment amount on or after the indicated date.

Pursuant to NRS 353.1467, credit card payments of $10,000 or more are not permitted and cannot be split between multiple payments and/or card types.

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