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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.
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