Contractor Licensing Section Form - State Of Alaska (Page 7 of 8) in pdf

Contractor Licensing Section Form - State Of Alaska Page 7

TATE

ALASKA

Department of Commerce, Community, and Economic Development

Division of Corporations, Business and Professional Licensing

State Office Building, 333 Willoughby Avenue, 9

Floor

PO Box 110806

Juneau, AK 99811-0806

Phone: (907) 465-2550

RENEWAL CREDIT CARD PAYMENT

Do not email or fax credit card information. Mail this form with the completed renewal to the division.

Completion of this form is not proof of payment until the division processes the information contained herein.

If any information on this form is illegible, the form will be rejected. Please print.

Name of Applicant or Licensee:

Corporate or Individual (first, middle, last)

(if applicable)

Type of License:

License Number

I wish to make payment by credit card for the following (check all that apply):

Amount

License (or renewal) fee

Fine

(specify)

Other

Total:

Print Name on Credit Card:

Complete Mailing Address:

Telephone Number:

Email Address (optional):

Credit Card Type (check one):

VISA

MASTERCARD

Signature of Credit Card Holder:

Card Number: ____________________________________ Expiration Date: _____________

The bottom section of this form will be destroyed upon processing of the payment.

08-4438R

Rev. 05/28/14

Contractor Licensing Section Form - State Of Alaska Page 7