Transcription of Credit Card Authorization Form - Ontario
1 SR-LV-034E (2017/01) Queen's Printer for Ontario , 2017 Disponible en fran aisCredit 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 The personal information provided by you on this form is collected to assist with payment verification for the Ministry of Transportation s driver, vehicle and carrier products and services, for which the Ministry is responsible under the Highway Traffic Act.
2 Note: Under provincial legislation, a false statement from the applicant may result in a Use Only Operator Number Office NumberBusiness Date (yyyy/mm/dd) Fee PaidApplicant's InformationName/Company/DealerAddressUni t/Apt/Suite NumberStreet NumberStreet NamePO BoxRural RouteLot NumberConcessionTownshipCity/TownProvinc e/StatePostal Code/Zip CodeCountryDaytime Telephone Telephone NumberEmail AddressOntario Identification NumberPlease select and provide one (1) of the Ontario identification numbers 's Licence (DL) NumberLicence Plate NumberRegistrant Identification Number (RIN)
3 Dealer NumberCommercial Vehicle Operator's Registration (CVOR) Number National Safety Code (NSC) NumberMotor Vehicle Inspection Station (MVIS) NumberVehicle Identification Number (VIN)If you do not have any of the Ontario identification numbers requested please select Not AvailableCredit card InformationName of the Credit card CompanyName of Cardholder as it appears on the Credit cardVisaMaster CardName of the Signing Authority (If different than name of Cardholder)Signature of Cardholder or Signing AuthorityDate (yyyy/mm/dd)SR-LV-034E (2016/12) Queen's Printer for Ontario , 2016 Disponible en fran ais Medium Sensitivity when completedCredit card NumberCard Expiration Date (mm/yy)
