Form 08-561 - Contact Information And Credit Card Payment Page 3

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T
S
HE
TATE
ALASKA
FOR DIVISION USE ONLY
of
Department of Commerce, Community, and Economic Development
Division of Corporations, Business and Professional Licensing
State of Alaska
Department of Commerce, Community, and Economic Development
Division of Corporations, Business and Professional Licensing
333 Willoughby Avenue, 9th Floor, Juneau, AK 99801
PO Box 110806, Juneau, AK 99811
Phone: (907) 465-2550
Fax: (907) 465-2974
•
CREDIT CARD PAYMENT
For security purposes please do not email credit card information. Fax or mail this credit card
payment form to the Division. Completion of this form is not proof of payment until the Division
processes the information. If any information on this form is illegible, the form will be rejected.
Name of Applicant or Licensee:
________________________________________________________________________________________________________________________
Type of License:
License Number (if applicable):
_____________________________________________________
____________________________________
Amount
I wish t o mak e payment by credit card for the following (check all that apply):
Application Fee:
__________________________________________________________________
_______________________
License or Renewal Fee:
__________________________________________________________________
_______________________
Other (name change, wall certificate, fine, duplicate license, exam, etc.):
1.
__________________________________________________________________
_______________________
2.
__________________________________________________________________
_______________________
Total:
_______________________
Name (as shown on credit card):
________________________________________________________________________________________________________________________
Mailing Address:
____________________________________________________________________________________________________________________________________________________
Phone:
Email (optional):
______________________________________________
___________________________________________________________________________________
Credit Card Type:
VISA
— or —
Mastercard
Signature of Credit Card Holder:
___________________________________________________________________________________________________
VISA or Mastercard Number:
Expiration Date:
__________________________________________________________
______________________________
This section below the dotted line will be destroyed upon processing of the payment.
08-4438
Rev. 4/6/16
Credit Card Payment Form

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