Form # 05-11a - Commercial Fisheries Entry Commission 2010 Commercial Vessel License Application Page 3
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38800 Glacier Hwy. #109
Commercial Fisheries Entry Commission
P.O. Box 110302, Juneau, Alaska 99811-0302
Credit Card Authorization
Phone: (907)789-6150/Fax: (907)789-6170
Please complete this form and return with your application if you wish to use your
credit card to pay for any fees due on permit(s), vessel(s) or other transactions
with CFEC. If you are paying with a check or money order please disregard this form.
Part I:
Payment Information
Permit fees:
$__________________ Permit number(s):
__________________________________
Vessel fees:
$__________________ Vessel ADF&G number(s):
____________________________
Transfer fees:
$__________________ Transfer type: _________________________________________
Mail fees:
$__________________ Mail type:
_________________________________________
Total fees:
$__________________
Part II:
Credit Card Information
____ Visa
____ Mastercard
____ Discover
___________________________________
_________________________________________
Credit card holder name
Billing address
___________________________
_______
______________
_______________________
City
State
Zip
3 Digit security code
____________ - ____________ - ____________ - ____________
_____________
Credit card number
Expiration date
Part III:
Shipping Information
Please indicate if you would like ____priority mail ____express mail ____fi rst class mail.
For express mail and priority mail fees check for current rates at:
In addition to the USPS mailing fee the Entry Commission charges an additional service fee of $10.00.
No mailing fee or service fees are charged for fi rst class mail.
We do not accept checks, money orders or cash for express or priority mail fees.
Part IV:
Signature
____________________________________________
________________
Signature of credit card holder
Date
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