Secretary of State CREDIT CARD FORM 31st Annual Election Law Seminar for Cities, Schools and Other Political Subdivisions December 4 - 6, 2019 Name on Card: County/Entity: Billing Address: City: Phone #: State: Zip Code: Email: Registration Confirmation and Seminar Information will be sent to email address provided below. (1): Attendee's Name E-mail: (2): (3): (4): (5): If faxed or postmarked after November 1, the Late Registration Fee is $250.00 Registration Fee(s) @ $250.00 Total Due: Credit Card #: Type of Card: Exp. Date: 3-digit CVV Code or 4-digit CID Code: By signing here, you authorize the above amount to be charged to your credit card. ------------------------------------------- ------------------------------------------ -------------------------------------- -------------------------------------- -------------------------------------- -------------------------------------- ------------------------------------------- ------------------------------------------ Fax, mail or email to: Office of the Secretary of State, Attn: Special Projects P.O. Box 12060, Austin, Texas 78711-2060 Fax: 512.463.7552 | E-mail: [email protected]