GOVERNMENT OF THE VIRGIN ISLANDS 
OF THE UNITED STATES 
   OFFICE OF THE LIEUTENANT GOVERNOR 
  5049 Kongens Gade, St. Thomas, Virgin Islands 00802 
 NOTARY DIVISION 
NOTARY CREDIT CARD AUTHORIZATION FORM 
Please print, sign and return this authorization form to our office by Postal Mail. 
 (Please provide a copy of your personal identification e.g. driver’s license or passport) 
Date:  __________      Cardholder Name: ________________________ 
Email: __________________________________ 
Contact Phone Number:  1 ________________________
Billing Address: ____________________________ 
      ____________________________ 
      __________________________ 
Credit Card Type or: 
ATM/ATH CARD  
 
Print Name:  
Signature: _ 
(   )
SIGN