THE  TATES
                     of 
                                                    Department of Commerce, Community, and Economic Development 
                                                    Division of Corporations, Business and Professional Licensing                
                          ALASKA 
                                           Construction Contractors Program 
                                           PO Box 110806, Juneau, AK 99811 
                                                    Phone: (907) 465-2550 
                                    Email: ConstructionContractors@Alaska.Gov 
                          Website: ProfessionalLicense.Alaska.Gov/ConstructionContractors 

Mechanical Contractor Registration Application Instructions 

The following must be received by the division before your application for Mechanical Contractor Registration can be 
reviewed:  

1. APPLICATION
   A completed application, signed and notarized (#08-4817, pages 1-4).
   a.      Doing Business As (DBA) name;
   b.      For Corporations or LLCs: Name and Alaska entity number registered with the Corporations section of the Division. Your
           business  entity  must  be  registered  with  the  Corporations  Division  before  your  Mechanical  Contractor  Registration
           Application  will  be  processed.  For  information  concerning  these  requirements,  contact  the  Corporations  section  at
           Corporations.Alaska.Gov
   c.      Names of all owners and principal officers or principal members.

2. FEES
   Fees made payable to “State of Alaska.”
   Nonrefundable Application Fee:           $100.00 
   Registration Fee:                        $250.00 
   Total Fees Due:                          $350.00 

3. INSURANCE
   Proof of current general liability insurance is required for registration (not less than $20,000 for damage to property, $50,000 for
   injury, including death, to any one person, and $100,000 for injury, including death, to more than one person).  The Certificate of
   Insurance Coverage form (#08-4817a) included with this packet or a certificate issued by your provider may be accepted.
   Your bond and insurance documents must be dated no more than 30 days from the date received in our office, and your business
   name(s)  on  your  insurance  documents  must  exactly  match  your  business  name(s)  on  your  application.  This  includes  your
   corporation (if applicable) and doing business as (DBA) name(s). For further guidance on how and when the bond and insurance
   documents  must  be  completed,  please  review  the  Construction  Contractor  FAQs,  specifically  question  #13,  available  at
   https://www.commerce.alaska.gov/web/cbpl/ProfessionalLicensing/ConstructionContractors/ConstructionContractorsFAQs.aspx.

4. WORKERS’ COMPENSATION
   If your business uses employee labor or your business is a Corporation or LLC, proof of workers’ compensation insurance is
   required for registration.  The Workers’ Compensation Worksheet (form 08-4817c) may be used to determine the appropriate
   workers’ compensation coverage required.
   Your bond and insurance documents must be dated no more than 30 days from the date received in our office, and your business
   name(s)  on  your  insurance  documents  must  exactly  match  your  business  name(s)  on  your  application.  This  includes  your
   corporation (if applicable) and doing business as (DBA) name(s). For further guidance on how and when the bond and insurance
   documents  must  be  completed,  please  review  the  Construction  Contractor  FAQs,  specifically  question  #13,  available  at
   https://www.commerce.alaska.gov/web/cbpl/ProfessionalLicensing/ConstructionContractors/ConstructionContractorsFAQs.aspx.
   A completed Workers’ Compensation Worksheet (form 08-4817c) is required to be submitted with the application;
   - And –
   A certificate from a workers’ compensation insurance carrier authorized by the Alaska Division or Insurance to transact business
   in Alaska is required to be included with the application.

08-4817 (Rev. 08/31/2022)                            Application Instructions                                    Page 1 of 2 

5. BONDING
   A bond of $10,000.00 is required to register as a Mechanical Contractor.
   Your bond and insurance documents must be dated no more than 30 days from the date received in our office, and your business
   name(s)  on  your  insurance  documents  must  exactly  match  your  business  name(s)  on  your  application.  This  includes  your
   corporation (if applicable) and doing business as (DBA) name(s). For further guidance on how and when the bond and insurance
   documents  must  be  completed,  please  review  the  Construction  Contractor  FAQs,  specifically  question  #13,  available  at
   https://www.commerce.alaska.gov/web/cbpl/ProfessionalLicensing/ConstructionContractors/ConstructionContractorsFAQs.aspx.
   One of the following must be submitted with the application for registration.
   a. Surety Bond.        Issued by an insurer or other surety company using the Construction Contractor Surety Bond form (#08-
      4817b) with the bonding company’s power of attorney included with it.  The bond form must be signed by both the
      principal (construction contractor) and the surety (bond provider); or
   b. Cashier’s Check.    For a cash deposit to the State of Alaska to be held in a trust account established by the state.
   c. Time Certificate of Deposit or Savings Passbook. Issued by a bank or trust company authorized to do business in Alaska.
      The certificate or passbook must read “State of Alaska in trust for (contractor name)”.  The original certificate or passbook
      will be held by the State.

08-4817 (Rev. 08/31/2022)        Application Instructions                         Page 2 of 2 

General Information 

APPLICATION PROCESSING: 
The average time to process a paper application varies by program but can take several weeks from the date it is received in this office 
complete with all correct forms, supporting documents and appropriate fees paid. When the application is complete and correct, and 
all supporting documents have been received and all fees have been paid, the license will be issued. Start the process far enough in 
advance to allow for processing time. Applications are reviewed in order of receipt in our office, and walk-in customers should not 
expect immediate review.  
LICENSE TERM: 
There is no “inactive” status. If you choose not to renew your license, it will lapse. Licenses are issued for a two-year period and expire 
on December 31 of even-numbered years, regardless of the date of issuance, except licenses issued within 90 days of the expiration 
date are issued to the next biennial expiration date. One renewal notice will be mailed at least 30 days before license expiration to 
the last known address of record. 
PROFESSIONAL FITNESS QUESTIONS: 
A “yes” response in the application does not mean your application will be denied. If you have responded “yes” to any professional 
fitness questions in the application, be sure to submit a signed and dated explanation, and the charging document and judgement. 
DENIAL OF APPLICATION: 
Please be aware that the denial of an application of licensure may be reported to any person, professional licensing board, federal, 
state, or local governmental agency, or other entity making a relevant inquiry or as may be required by law. 
RANDOM AUDIT: 
If your program requires continuing education, the Division will audit a percentage of the license renewals. If your license is randomly 
selected for audit, a letter will be sent with instructions to submit documentation as proof you satisfied the continuing competency 
requirements as stated on this renewal form.  Licensees are randomly selected by computer and may be randomly selected as often 
as the computer program chooses. You must save your documents for at least four years so you can respond to audits. 
ADDRESS OR NAME CHANGE: 
In accordance with 12 AAC 02.900, it is the applicant's/licensee's responsibility to notify the Division, in writing, of changes of address 
or name. Name and address change notification forms are available on the Division’s website. The address of record with the division 
will be used to send renewals and all other official notifications and correspondence. The name appearing on the license must be your 
current legal name. 
CERTIFIED TRUE COPIES:  
If any of the required documents will be issued under a former name, indicate on the application and submit marriage license and/or 
court documents that are notarized as a “certified true copy of the original document”. To obtain a certified true copy, you must 
present the notary with the original document along with the photocopy. You must write, “I certify this is a true copy of the original 
document” and sign your name. The notary will compare the original document with the copy and then notarize your signature. 

SOCIAL SECURITY NUMBERS: 
AS 08.01.060 and 08.01.100 require that a U.S. Social Security Number be on file with the division before a professional license is 
issued or renewed for an individual. If you do not have a U.S. Social Security Number, please complete the Request for Exemption 
from Social Security Number Requirement form (#08-4372) located at ProfessionalLicense.Alaska.Gov or contact the division for a 
copy of the form. This form is required with every application if you do not have a U.S. Social Security Number. 
PUBLIC INFORMATION: 
Please be aware that all information on the application form will be available to the public, unless required to be kept confidential by 
state  or  federal  law.  Information  about  current  licensees,  including  mailing  addresses,  is  available  on  the  division’s  website  at 
ProfessionalLicense.Alaska.Gov under License Search. 
ABANDONED APPLICATIONS:  
Under 12 AAC 02.910, an application is considered abandoned when 12 months have elapsed since correspondence was last received 
from or on behalf of the applicant. An abandoned application is denied without prejudice. At the time of abandonment, the division 
will send notification to the last known address of the applicant, who has 30 days to submit a written request for a refund of biennial 
license and other fees paid. The application fee will not be refunded. If no request for refund is received within that timeframe, no 
refund will be issued, and all fees will be forfeited. 

BUSINESS LICENSES: 
The status of a professional license will directly impact the status of an associated business license. Renewal applications for business 
licenses are mailed separately. For more information about business licenses, (907) 465-2550 or BusinessLicense.Alaska.Gov 

08-4817 (Rev. 08/31/2022)                                 General Information                                          Page 1 of 2 

STALE DOCUMENTS: 
Application forms, authorizations and verifications older than 12 months from the date the document was received by the division 
will be considered stale; the document must be resubmitted as appropriate before the application will be considered by the division 
or a licensing board. Application documents include the application documents and verifications of licensure from other licensing 
jurisdictions. (12 AAC 02.915) 
PAYMENT OF CHILD SUPPORT:  
If  the Alaska Child Support  Enforcement  Division  has determined  that you are in  arrears on  child support, you  may be  issued  a 
nonrenewable temporary license valid for 150 days. Contact Child Support Services at (907) 269-6900 to resolve payment issues. 
STATUTES AND REGULATIONS: 
The complete set of statutes and regulations for this program are available by written request or online at the division’s website: 
ProfessionalLicense.Alaska.Gov 
If you would like to receive notice of all proposed regulation changes for your program, please send a request in writing with your 
name, preferred contact method (mail or email), and the specific program you want to be updated on to the address below. 
                                      Regulations Specialist 
                               Department of Commerce, Community, and Economic Development 
                               Division of Corporations, Business and Professional Licensing 
                               EMAIL: RegulationsAndPublicComment@Alaska.Gov 

08-4817 (Rev. 08/31/2022)                General Information                                    Page 2 of 2 

                  THE  TATES                                                                                             CON 
                    of                                                                                             FOR DIVISION USE ONLY 
                    ALASKA 
                  Department of Commerce, Community, and Economic Development 
                  Division of Corporations, Business and Professional Licensing 

      Construction Contractors Program 
      PO Box 110806, Juneau, AK 99811 
      Phone: (907) 465-2550 
      Email: ConstructionContractors@Alaska.Gov 
      Website: ProfessionalLicense.Alaska.Gov/ConstructionContractors 

Mechanical Contractor Registration Application  

PART I         Application Type 

Application Type:         New Application                       Owner/Entity Change (Existing Licenses ONLY) 

PART II        Payment of Fees 

                          Nonrefundable Application Fee                                                                  $100.00 
Required Fees: 
                          Registration Fee                                                                               $250.00 

PART III        Registration Information 
Doing Business As: 
(DBA) 
                            P.O. Box or  Street                                            City                 State       Zip 
Mailing Address: 

Contact Phone: 
EMAIL AGREEMENT: By choosing to receive correspondence on any matter affecting my license or other business with the Alaska Division of Corporations, Business 
and Professional Licensing, I agree to maintain an accurate email address through the MY LICENSE web page. I understand that failure to check my email account or 
to keep the email address in good standing may result in an inability to receive crucial information, potentially resulting in my inability to obtain or maintain licensure. 
                                                                                                              Send my Correspondence Electronically 
Email Address:                                                                                   Select One:  
                                                                                                              Send my Correspondence by Mail 
Corporation, LLC, LP or LLP 
Are you a Corporation, LLC, LP or LLP? 
Reminder: If you are a corporation or LLC your business entity must be registered with           Yes          No 
the Corporations Division before this application is processed. 
                                                                IF YES, provide: 
Name of Alaska                                                                                       Alaska Entity 
Corporation or LLC:                                                                                  Number: 
Owner or Entity Name Changes 

Are you changing the Owner or Entity name on an existing license?                                Yes          No 

                                                                IF YES, provide: 

License Number: 

08-4817 (Rev. 08/31/2022)                               Mechanical Contractor Registration Application                     Page 1 of 4 

PART IV Ownership Information 
Check the applicable box and provide the complete name(s) of the owner(s) including all partners, corporate officers, or managing 
members, whichever is appropriate; and provide U.S. Social Security Numbers and birthdates for sole proprietor or partners.  AS 
08.01.060 requires you to provide your United States Social Security Number. It is considered confidential information and will not 
be publicly disclosed; it may be used to verify inter-state licensure. 

      Sole Proprietorship             Partnership                                Corporation             LLC 

      Full Name                       Address                                    Social Security Number*            Date of Birth* 

*Sole Proprietorship and Partners Only

PART V  Insurance 
Give proof of current general liability insurance to register as a Mechanical Contractor. AS 08.18.101(a)(2) & (b). 
Your bond and insurance documents must be dated no more than 30 days from the date received in our office, and your business 
name(s)  on  your  insurance  documents  must  exactly  match  your  business  name(s)  on  your  application.  This  includes  your 
corporation (if applicable) and doing business as (DBA) name(s). For further guidance on how and when the bond and insurance 
documents  must  be  completed,  please  review  the  Construction  Contractor  FAQs,  specifically  question  #13,  available  at 
https://www.commerce.alaska.gov/web/cbpl/ProfessionalLicensing/ConstructionContractors/ConstructionContractorsFAQs.aspx.            
I have completed the attached Certificate of Insurance Coverage (form 08-4817a) or attached a certificate issued by my 
provider to this application as proof of public liability and property damage insurance covering contracting operations in this 
state in the sum of not less than $20,000 for damage to property, $50,000 for injury, including death, to any one person, and 
$100,000 for injury, including death, to more than one person.  

PART VI Workers’ Compensation 
Your bond and insurance documents must be dated no more than 30 days from the date received in our office, and your business 
name(s)  on  your  insurance  documents  must  exactly  match  your  business  name(s)  on  your  application.  This  includes  your 
corporation (if applicable) and doing business as (DBA) name(s). For further guidance on how and when the bond and insurance 
documents  must  be  completed,  please  review  the  Construction  Contractor  FAQs,  specifically  question  #13,  available  at 
https://www.commerce.alaska.gov/web/cbpl/ProfessionalLicensing/ConstructionContractors/ConstructionContractorsFAQs.aspx.            
I have completed the Workers’ Compensation Worksheet (#08-4817c) and 
                                                                                 Yes         No 
included it with this application. 
Is the documentation/certificate showing workers’ compensation included in 
                                                                                 Yes         No 
this application? 

If No, please state the reason (i.e., sole proprietor with no employees, etc.):  

08-4817 (Rev. 08/31/2022)                  Mechanical Contractor Registration Application                             Page 2 of 4 

PART VII     Bonding 
A bond of $10,000.00 is required to be registered as a Mechanical Contractor pursuant to AS 08.18.071. 
Your bond and insurance documents must be dated no more than 30 days from the date received in our office, and your business 
name(s)  on  your  insurance  documents  must  exactly  match  your  business  name(s)  on  your  application.  This  includes  your 
corporation (if applicable) and doing business as (DBA) name(s). For further guidance on how and when the bond and insurance 
documents  must  be  completed,  please  review  the  Construction  Contractor  FAQs,  specifically  question  #13,  available  at 
https://www.commerce.alaska.gov/web/cbpl/ProfessionalLicensing/ConstructionContractors/ConstructionContractorsFAQs.aspx.  

Please check the appropriate box below: 

      I have provided original documentation or a copy of my surety bond (#08-4817b). 
- or -
      I have provided an original Time Certificate of Deposit or Savings Passbook issued by a bank or trust company authorized 
      to do business in Alaska.  The certificate or passbook must read “State of Alaska in Trust for (contractor name).” 
- or -
      I have provided a cashier’s check for a cash deposit to the State of Alaska to be held in a trust account established by the 
      state. 

08-4817 (Rev. 08/31/2022)                    Mechanical Contractor Registration Application              Page 3 of 4

         THE  TATES                                                                         CON 
         of                                                                                 FOR DIVISION USE ONLY 
             ALASKA 
         Department of Commerce, Community, and Economic Development 
         Division of Corporations, Business and Professional Licensing 

Construction Contractors Program 
PO Box 110806, Juneau, AK 99811 
Phone: (907) 465-2550 
Email: ConstructionContractors@Alaska.Gov 
Website: ProfessionalLicense.Alaska.Gov/ConstructionContractors 

Notary Signature Page 

PART VIII  Notarized Signature 

I hereby certify that I am the person herein named and subscribing to this application and that I have read the complete 
application, and I know the full content thereof. I declare that all of the information contained herein, and evidence or 
other documents submitted herewith are true and correct. 
I understand that any falsification or misrepresentation of any item or response in this application, or any attachment 
hereto, or falsification or misrepresentation of documents to support this application, is sufficient grounds for denying, 
revoking, or otherwise disciplining a license or permit to practice in the state of Alaska. 
I further understand that it is a Class A misdemeanor under Alaska Statute 11.56.210 to falsify an application and commit 
the crime of unsworn falsification. 
A  person  who  makes  a  false  statement  on  this  application  may  be  subject  to  civil  and  criminal  penalties,  including 
prosecution for perjury (AS 11.56.200 & AS 11.56.230). 

                          Owner, Corporate Officer, 
Notary Stamp              or Member Printed Name: 

                          Owner, Corporate Officer, 
                          or Member Signature:   
                          Notary Public for                     Subscribed and Sworn to 
                          State of:                             Before me on this Day: 
                                                                       My Commission 
                          Notary Signature: 
                                                                       Expires: 

08-4817 (Rev. 08/31/2022)                Mechanical Contractor Registration Application       Page 4 of 4 

                      THE  TATES
                      of 
                                                    Department of Commerce, Community, and Economic Development 
                                                    Division of Corporations, Business and Professional Licensing                
                           ALASKA 
                                       Construction Contractors Program 
                                       PO Box 110806, Juneau, AK 99811 
                                                    Phone: (907) 465-2550 
                                       Email: ConstructionContractors@Alaska.Gov 
                              Website: ProfessionalLicense.Alaska.Gov/ConstructionContractors 

Certificate of Insurance Coverage 

Submit this completed original form or a Certificate of Insurance issued by your provider with the Mechanical Contractor Application. 
Your bond and insurance documents must be dated no more than 30 days from the date received in our office, and your business 
name(s) on your insurance documents must exactly match your business name(s) on your application. This includes your corporation 
(if applicable) and doing business as (DBA) name(s). For further guidance on how and when the bond and insurance documents must 
be completed, please review the Construction Contractor FAQs, specifically question #13, available at 
https://www.commerce.alaska.gov/web/cbpl/ProfessionalLicensing/ConstructionContractors/ConstructionContractorsFAQs.aspx.            

Corporation, Sole Proprietor, 
or All Partners’ Name(s):  
Doing Business As Name: 
(DBA)   
                                                                          Amount Insured:  
Policy Number(s): 
                                                                          (Per AS 08.18.101) 
Effective Date:                                                           Effective Date: 
(Start)                                                                   (End) 

By the signature below we hereby certify that we are a duly authorized casualty insurer eligible to write business in the State of 
Alaska and have written a public liability policy of not less than the limits required under AS 08.18 on behalf of the Construction 
Contractor/DBA named above for registration as a Mechanical Contractor under the policy information listed above. 
In the event the above policy is cancelled for any reason, we agree to furnish the Department of Commerce, Community, and 
Economic Development, Construction Contractors Section, at the above address, a NOTIFICATION OF CANCELLATION at least 30 
day before the effective date of that cancellation. 

Name of Insurance 
Carrier (Not Agency): 
                             Street                   City                                  State        Zip       
Address:  

Signature of 
                                                                                Date Signed: 
Authorized Agent: 

08-4817a (Rev. 08/31/2022)                             Certificate of Insurance Coverage                               Page 1 of 1 

                     THE  TATES
                     of 
                                               Department of Commerce, Community, and Economic Development 
                                               Division of Corporations, Business and Professional Licensing                
                           ALASKA 
                                              Construction Contractors Program 
                                              PO Box 110806, Juneau, AK 99811 
                                               Phone: (907) 465-2550 
                                         Email: ConstructionContractors@Alaska.Gov 
                           Website: ProfessionalLicense.Alaska.Gov/ConstructionContractors 

Construction Contractor Surety Bond (Required by Construction Contractor Statute AS 08.18.07) 
Your bond and insurance documents must be dated no more than 30 days from the date received in our office, and your business 
name(s) on your insurance documents must exactly match your business name(s) on your application. This includes your corporation 
(if applicable) and doing business as (DBA) name(s). For further guidance on how and when the bond and insurance documents must 
be completed, please review the Construction Contractor FAQs, specifically question #13, available at 
https://www.commerce.alaska.gov/web/cbpl/ProfessionalLicensing/ConstructionContractors/ConstructionContractorsFAQs.aspx.         
Principal Name: 
(Applicant) 

DBA Name: 
                                               Effective                  mm/dd/yyyy Expiration                      mm/dd/yyyy 
Bond Number: 
                                               Date:                                 Date: 
KNOW ALL MEN BY THESE PRESENTS that we, the above-named construction contractor, as principal, and the agency named below, 
as surety, are held firmly bound to the State of Alaska, in the sum of TEN THOUSAND DOLLARS ($10,000) lawful money of the United 
States, for the payment of which, well and truly to be made, we and each of us, bind ourselves, our heirs, executors, administrators, 
successors and assigns, jointly and severally, firmly by these presents.  
THE CONDITIONS OF THE ABOVE OBLIGATIONS ARE SUCH THAT: Whereas, the above bound principal has applied to, or is about to 
obtain from, the State of Alaska for registration as a Mechanical Contractor pursuant to AS 08.18.011 and the acts amendatory thereof 
and supplemental there to: 
NOW THEREFORE, if the State of Alaska shall register the above bounden principal as a Mechanical Contractor and that principal shall 
faithfully and honestly act a Mechanical Contractor in accordance with law, and fully complies with the provisions of AS 08.18.071 of 
the State of Alaska and acts thereof and supplemental thereto, and if the principal shall fully indemnify and save harmless from loss 
the State of Alaska and any person who may have cause of action against the principal for any malfeasance or misfeasance in the 
conduct of a Mechanical Contractor, then this obligation to be voided, otherwise to remain in full force and virtue. 
LIABILITY UNDER THIS BOND commences on the date listed above and shall be continuous until the registration license is revoked or 
otherwise terminated by the Department of Commerce, Community, and Economic Development, State of Alaska (the Department) 
or until written notice from the Surety is received by the Department provided the bond has been cancelled for lawful reasons. The 
bond shall apply to all liens and liabilities which arise during the effective period of the bond to which the bond is applicable under 
law, even if the judgment liens are foreclosed or valid liens settled after the effective period of the bond or liabilities are enforced 
after the effective period of the bond.  
IN WITNESS OF THE ABOVE, principal and surety have signed and sealed this bond on the date listed below. 
Principal Signature: 
                                                                                     Date Signed: 
(Applicant) 

Surety Name: 

Surety Signature:                                                                    Date Signed: 

Attorney-in-Fact:                                        Agency Name: 
                             Street                        City                         State                           Zip 
Agency Address: 

THIS BOND IS NOT VALID UNTIL SIGNED BY BOTH PRINCIPAL AND SURETY.                                     Surety’s Seal 
Surety's Power of Attorney must be attached.                                                            (Required) 

08-4817b (Rev. 08/31/2022)                                 Surety Bond                                                 Page 1 of 1 

                     THE  TATES
                      of 
                                               Department of Commerce, Community, and Economic Development 
                                               Division of Corporations, Business and Professional Licensing                
                           ALASKA 
                                               Construction Contractors Program 
                                               PO Box 110806, Juneau, AK 99811 
                                               Phone: (907) 465-2550 
                                    Email: ConstructionContractors@Alaska.Gov 
                           Website: ProfessionalLicense.Alaska.Gov/ConstructionContractors 

Workers’ Compensation Worksheet 
If your business uses employee labor, or if your business is a corporation or LLC, you must provide proof of workers compensation 
insurance by a certificate of insurance issued by a carrier authorized by the Alaska Division of Insurance to transact business in 
Alaska.  This certificate must include the following six items: 1) name of the insured exactly as licensed, 2) the DBA, 3) name of the 
insurance provider, 4) policy number, 5) commencement date and 6) expiration date.  
Your bond and insurance documents must be dated no more than 30 days from the date received in our office, and your business 
name(s) on your insurance documents must exactly match your business name(s) on your application. This includes your corporation 
(if applicable) and doing business as (DBA) name(s). For further guidance on how and when the bond and insurance documents must 
be completed, please review the Construction Contractor FAQs, specifically question #13, available at 
https://www.commerce.alaska.gov/web/cbpl/ProfessionalLicensing/ConstructionContractors/ConstructionContractorsFAQs.aspx.

Doing Business As:                                                             Construction Contractor 
(DBA)                                                                          License Number:  

Are you a sole proprietor or partnership with employees?                            Yes                No 

Are you a Limited Liability Company (LLC) or Corporation with employees? 
Please note: There are no exemptions for family, friends, or non-residents, or 
for part-time or temporary jobs.  Do not classify workers as “independent           Yes                No 
contractors”  without  calling  the  Alaska  Workers’  Compensation  Division 
Special Investigations Unit at (907) 269-4002. 

If YES to either of the above questions, please check the appropriate box below: 
Sole Proprietorship: 
      I am a sole proprietor and have workers compensation insurance coverage for all my employees, excluding myself as the 
      owner, and I have attached the necessary certificate to this application. 
- or -
      I am a sole proprietor and have workers compensation insurance coverage for all my employees including myself, and 
      I have attached the necessary certificate to this application. 

Partnership: 
      We are a partnership and have workers compensation insurance coverage for all employees, excluding the owners, and 
      we have attached the necessary certificate to this application. 
- or -
      We are a partnership and have workers compensation insurance coverage for all employees including the owners, and 
      we have attached the necessary certificate to this application. 

Limited Liability Company (LLC): 
      We are an LLC and have workers compensation insurance coverage for all employees excluding any members who own 
      10% or greater of this company (members who own 9% or less are required to be covered by workers compensation 
      insurance), and we have attached the necessary certificate to this application. 
Corporation: 
      We are a Corporation and have workers compensation insurance coverage for all employees excluding any officers or 
      members who own 10% or greater of this company (officers or members who own 9% or less are required to be covered 
      by workers compensation insurance), and  we have attached the necessary certificate to this application. 

08-4817c (Rev. 08/31/2022)                      Workers’ Compensation Worksheet                                  Page 1 of 1 

              THE  TATE S                                                                                                  FOR DIVISION USE ONLY 
                of 
                  ALASKA 
              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 
        PO Box 110806, Juneau, AK 99811 
        Phone: (907) 465-2550 

Credit Card Payment Form 

All major credit cards are accepted. For security purposes, do not email credit card information. 
Include this credit card payment form with your application.  

Name of Applicant or Licensee:      _________________________________________________________________________________________________________________________ 

Program Type:   ________________________________________________________       License Number (if applicable):                      ________________________________ 

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

        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 Number:   ________________________________________________________      Email (optional):               _______________________________________________________ 

Signature of Credit Card Holder:              _____________________________________________________________________________________________________________________ 

 08-4438                   Rev 12/26/18                   Credit Card Payment Form (all major cards accepted) 

   CREDIT CARD INFO:  Your payment cannot be processed unless all fields are completed! 

   1.    Account Number:                                                                                      All four fields MUST 
                                                                                                                                    be completed! 
   2.    Expiration Date:
                                                                                                              This section will be 
   3.    Billing ZIP Code:
                                                                                                              destroyed after the 
   4.    Security Code:                                                                                       payment is processed.