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Physician Registration Form
 
I, the undersigned present
Medical License #
for the records of the office of the City Clerk. I intend to conduct the practice of medicine in the City of Boston

My office or usual place of business
Street:
City:
State:
Zip:

The required fee of $100.00 is herewith tendered

Bank Routing #:
Account #:
Account Holder Name:

Under penalties of perjury, I declare that I have examined this application, and to the best of my knowledge and belief, the information is true, correct and complete. Signed and dated

Print Name:
E-Mail Address:
Date:  7/19/2008


NOTE:
The image below depicts the bottom of your check. Please find these numbers in your checkbook and fill out the fields above.
check

If you have questions or concerns about direct debit online payment, please contact online payments at OnlinePayments@cityofboston.gov

If you have technical questions about the online direct debit payment (regarding technical issues while making an online payment), please contact the Webmaster@cityofboston.gov
ON-LINE PAYMENT AGREEMENT:
By completing and submitting the information, I hereby authorize the City of Boston (COB) to initiate a direct debit from the identified financial institution's savings or checking/NOW account for the payment of the selected property tax bill. I understand that this one time agreement is applicable to this specific transaction. I further understand the COB reserves the right to limit participation to payors whose accounts are in good standing.
IMPORTANT USER RESPONSIBILITIES:

 

  • If the information was incorrect or if there was a problem with your account (wrong account number, blocked account, freeze on withholding, insufficient funds, etc.) the payment will be rejected.
  • This service is offered as a convenience to taxpayers and is free of charge. Clicking the "PAY" button does not relieve a user from the above responsibilites. Your account data is forwarded securely to the bank for processing and its accuracy cannot be instantly verified.








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