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 Handyman Contractor Registration Application Instructions The following must be received by the division before your application for General Contractor Registration can be reviewed: 1. APPLICATION A completed application, signed and notarized (#08-4816, 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 Handyman 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 (#08-4816a) 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. A certificate from a workers’ compensation insurance carrier authorized by the Alaska Division of Insurance to transact business in Alaska is required to be included with the 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. 5. BONDING A bond of $5,000.00 is required to register as a Handyman 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. 08-4816 (Rev. 08/31/2022) Application Instructions Page 1 of 2 |
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- 4816b) 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 and must be accompanied by an Assignment of Cash Deposit form (#08-4816c). 08-4816 (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 08-4816 (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 08-4816 (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 Handyman 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: (Required 12 AAC 21.030) 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: 08-4816 (Rev. 08/31/2022) Handyman 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 Social Security % of Full Name Address Date of Birth* Number* Ownership *Sole Proprietorship and Partners Only PART V Insurance Give proof of current general liability insurance to register as a Handyman 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 (#08-4816a) 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 Doing Business As: (DBA) 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. A policy with "AOS" or "All Other States" endorsement will only be accepted if the certificate specifically states, "covers activities in Alaska.” 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. 08-4816 (Rev. 08/31/2022) Handyman Contractor Registration Application Page 2 of 4 |
PART VI Workers’ Compensation (continued) 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. PART VII Bonding A bond of $5,000.00 is required to be registered as a Handyman 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 (#08-4816b). - 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. 08-4816 (Rev. 08/31/2022) Handyman 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: 08-4816 (Rev. 08/31/2022) Handyman 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 Handyman 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. Contractor Name: DBA Name: 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 Handyman 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: 08-4816a (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 FIVE THOUSAND DOLLARS ($5,000) 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 Handyman 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 Handyman Contractor and that principal shall faithfully and honestly act a Handyman 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 Handyman 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) 08-4816b (Rev. 08/31/2022) Surety Bond Page 1 of 1 |
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 Assignment of Cash Deposit 12 AAC 21.120(a)(2): The Time Certificate of Deposit MUST: Be payable to “State of Alaska in trust for” Be issued for at least three years and be automatically renewable Be signed by BOTH the contractor and the bank PART I Bank Information For value received, the undersigned assigns and transfers to the State of Alaska the following: Amount of Deposit Number: Deposit: Bank Name: Street City State Zip Bank Address: Bank Representative: By signature below, the issuing institution agrees that only the State of Alaska, upon presentation of written notice, shall cause the release of any and all funds described above. Bank Representative Name: Bank Representative Date Signed: Signature: PART II Contractor Information Owner or Entity Name: Email Address: Phone Number: Official DBA: If a handyman contractor license number has been issued to you, enter it here: 08-4816c (Rev. 08/31/2022) Assignment of Cash Deposit Page 1 of 2 |
PART III Notarized Signature Applicant and Notary: The undersigned irrevocably constitutes and appoints the State of Alaska by and through its duly authorized agents as his/her/their Attorney-in- Fact to do all things necessary and appropriate to effectuate the purposes of this assignment. It is agreed and understood that this assignment shall remain in full force and effect for the period of time provided by law for actions against the surety bond. The person who executed the below and foregoing Assignment of Cash Deposit acknowledged to me that it was signed and sealed freely and voluntarily for the uses and purposes stated in the assignment. All persons whose names appear on the certificate or passbook account must sign below. Applicant Printed Notary Stamp Name: Applicant Signature: Date: Notary Public for Subscribed and Sworn to State of: Before me on this Day: My Commission Notary Signature: Expires: 08-4816c (Rev. 08/31/2022) Assignment of Cash Deposit Page 2 of 2 |
THE STATE 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. |