Form ST-212 Alternate Payment Form

REPRODUCE LOCALLY. Include form number and date on all reproductions. Form Approved - OMB No. 0581-0251

USDA, Agricultural Marketing Service

Science and Technology Program Laboratory Approval & Testing Division

1400 Independence Avenue, SW Washington, DC 20250

Burden and Nondiscrimination Statements

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not

required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0581-0251. The time required to complete this information collection is estimated to average .0500 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, age, disability, and where applicable, sex, marital status, familial status, parental status, religion, sexual orientation, genetic information, political beliefs, reprisal, or because all or part of an individual’s income is derived from any public assistance program (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for communication of program information (Braille, large print, audiotape, etc.) should contact USDA’s TARGET Center at (202) 720-2600 (voice and TDD).

To file a complaint of discrimination, write to USDA, Director, Office of Civil Rights, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, or call (800) 795-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity provider and employer.

Privacy Act Advisory Statement

The Privacy Act of 1974 (P.L. 93-579) requires that you be given certain information in connection with the request for information solicited on the Alternate Payment Form (ST-212). Accordingly, pursuant to the requirements of the Act, please be advised that: (1) the authority for the collection of this information is 15 U.S.C. § 1113 or 35 U.S.C. § 41 and

37 CFR 1.16-1.28, 1.492, or 2.6-2.7; (2) furnishing of the information solicited is voluntary; and (3) the principal purpose for which the information is used by the Science and Technology Program (S&T) is to charge the appropriate fee amount to the appropriate credit card account. If you do not furnish the requested information, S&T may not be able to charge

the fee to the credit card or the credit card institution may refuse to accept the charge, either of which will result in the fee being treated as not having been paid.

Instructions for Completing the Alternate Payment Form

• Enter all company and contact information in the space provided.

• Check box for appropriate service provider (e.g. National Science Laboratories or Laboratory Approval Service); provide a brief description of the service provided: enter the Billing Document Number (TSB) or Invoice Number (Laboratory Programs).

• Enter the total payment amount to be charged to your account.

• Select payment option: either credit card or ACH

• For credit cards, check appropriate box and enter the name and number on the card.

• In order to process a credit card transaction, we require that you provide us with the 3-digit code found on the back of the card.

• For ACH transfers, enter the 9-digit routing number found at the bottom left of the check and the account number found at the bottom of the check to the right of the routing number.

• Remember to sign the form, date it and print your name below your signature. Science and Technology

Programs cannot process credit card payments without an authorized signature.

• You have the option to fax or mail your completed form to the S&T Payment Center.

• Completed forms should be mailed to the S&T Payment Center, USDA, AMS, S&T, LATD, NSL/LAS, 801 Summit

Crossing Place, Suite B, Gastonia, NC 28054-2105 or Faxed to 704-853-2800.

• Questions? 704-867-3873

ST-212 (06-14) designed by S&T Laboratory Approval Service (LAS) Page 1 of 2

United States Department of Agriculture Agricultural Marketing Service

Science and Technology Program

Laboratory Approval and Testing Division

ALTERNATE PAYMENT FORM

FAX or Mail Form to: Attn: Payment Center ^{USDA, AMS,} S&T, LATD, NSL/LAS

801 Summit Crossing Place, Suite B Gastonia, NC 28054-2105

FAX 704-853-2800

To make a payment to your account using a credit card or an electronic check (Automated Clearing House (ACH) , Debit) please fill in this form and fax or mail to the address shown above. Required fields indicated with an asterisk.

Company Name:* Account Number:* Address:*

Name of Contact^:*

City, State, Zip:*

Contact’s Phone:* _{Contact’s Email:*}

*Service Provider (check one): Laboratory Approval Svc National Science Laboratories (NSL)

Description of Service:

*Invoice or Billing Document No: ^{*Payment Amount:}

*Select Payment Option 1 or 2 by inserting an "X" into the appropriate box below

Option 1 Pay by Credit Card

American Express	Master Card	Diners Club/Carte Blanche
Discover	Visa

Select Credit Card:

Name as shown on Credit Card:

Number on Credit Card:

Expiration Date of Credit Card (mm/yy):

3 Digit Security Code:

The security code is found on either the front or back of the credit card. It usually follows the credit card number.

For payment we will need this code. For security purposes the code can be provided to the Payment Center over the telephone.

^Option 2 ^{Pay by} Electronic Check (ACH Debit)

Bank Routing Number: Checking Account Number:

By signing this application, I authorize the United States Department of Agriculture, Agricultural Marketing Service,

Science and Technology Program to use the above information for the purpose of collecting payment for services provided.

Questions? 704-867-3873

*

^{Cardholder Signature} Date

*

Print Name

For Office Use Only

Agency Tracking ID

_{Pay.Gov Tracking ID}

Processing Clerk's Name

ST-212-(06-14) designed by S&T Laboratory Approval Service (LAS)

Date Transaction Completed