Notaries Public Division • Credit Card Authorization 
Revised  4/ 2026 
GOVERNMENT OF THE VIRGIN ISLANDS
OF THE UNITED STATES
OFFICE OF THE LIEUTENANT GOVERNOR 
NOTARIES PUBLIC DIVISION 
5049 Kongens Gade  |  St. Thomas, Virgin Islands 00802 
 NOTARY CREDIT CARD AUTHORIZATION FORM 
Required: Include a legible copy of the cardholder’s government-issued photo identification 
(for example, a driver’s license or passport). Please print clearly, sign, and return this form by postal mail 
to the address above. 
CARDHOLDER INFORMATION 
Cardholder Name 
Date 
____ / ____ / ______ 
Email Address 
Phone Number 
1 (____) _____-_______ 
Billing Address 
City / State / ZIP 
PAYMENT INFORMATION 
Card Type 
☐Mastercard    ☐ Visa
☐ATH /ATM
Amount 
Authorized 
$  
Card Number 
_____ - _____ - _____ - _____ 
Expiration Date 
 ____ / ______ 
Security Code 
(CVV) 
(3-digit code located on the back of 
the credit card)  _____________ 
Payment 
Purpose 
Notary fee(s) ☐  
Apostille service(s)☐ 
CARDHOLDER AUTHORIZATION 
I authorize the Office of the Lieutenant Governor, Notaries Public Division, to charge the amount 
shown above to the payment card identified on this form. I certify that I am the authorized 
cardholder and that the information provided is accurate. 
Cardholder 
Printed Name 
Signature 
Date Signed 
____ / ____ / ______ 
SECURITY NOTICE: Do not send this completed form by unencrypted email. For your protection, the Division should retain and dispose of 
payment-card information in accordance with applicable records and security procedures. 
SIGN