State Library of Kansas Credit Card Payment Form

Please complete this form and submit it by 1) calling 785-296-3801   2) faxing it to 785-368-7291 or 3) mailing it to: State Library of Kansas, 300 SW 10 th Ave., Rm 343N, Topeka, KS 66612-1593

Name as appears on card: _________________________________________

Address: ____________________________________________________________________

Card Type:   Visa   Mastercard

Card Number: __ __ __ __   __ __ __ __   __ __ __ __   __ __ __ __

Expiration (mm/yy): __ __ / __ __

Security Code (3 digits on the back of the card): __ __ __

Amount: $ __________

What are you paying for? (eg: mailing labels, workshop registration, etc...):