Form Dms 004 - License, Id Card And Records Payment Authorization
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1DMS 004 (06/10/2015)
LICENSE, ID CARD AND RECORDS
PAYMENT AUTHORIZATION
Purpose:
Customers fax this form to DMV for payment authorization.
Instructions:
Do not mail this form. Fax the completed form to the applicable fax number listed in the Transaction/Fax
Information section.
CUSTOMER INFORMATION
NAME
DRIVER LICENSE/CUSTOMER NUMBER
MAILING ADDRESS
CITY
STATE
ZIP CODE (required)
BIRTH DATE (mm/dd/yyyy)
PAYMENT AUTHORIZATION
CREDIT CARD (check one)
NAME APPEARING ON CREDIT CARD
DAYTIME TELEPHONE NUMBER
AMOUNT TO BE CHARGED
MASTERCARD
VISA
$
(
)
CREDIT CARD NUMBER
EXPIRATION DATE (mm/yy)
AMERICAN
DISCOVER
EXPRESS
CARD HOLDER SIGNATURE
DATE (mm/dd/yyyy)
I authorize DMV to charge the credit card account listed.
TRANSACTION/FAX INFORMATION
Identify the applicable work center for the transaction you are completing and fax this completed form to the number provided.
License and ID Work Center
Customer Records Work Center
Fax Number: (804) 367-6710
Fax Number: (804) 367-1112
RENEWAL
REPLACEMENT
Driver's License
Driving Record
- (include Form CRD 93 - Information Request)
(include Form DL 1P - Driver's License and
Identification Card Application)
RENEWAL
REPLACEMENT
CDL License
Vehicle Record -
(include Form CRD 93 - Information Request)
(include Form DL 1P - Driver's License and
Identification Card Application)
RENEWAL
REPLACEMENT
Identification Card
Police Crash Report -
(include Form CRD 93 - Information Request)
(include Form DL 1P - Driver's License and
Identification Card Application)
ORIGINAL
REPLACEMENT
Veterans Identification Card
(include DL 11 - Virginia Veterans Identification
Card Application)
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Parent category: Legal