Free Credit Card Payment Form - Alaska


File Size: 66.4 kB
Pages: 1
File Format: PDF
State: Alaska
Category: Corporations
Author: lmbrown2
Word Count: 181 Words, 1,789 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.commerce.state.ak.us/occ/pub/adm4438.pdf

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OFFICE USE ONLY State of Alaska Department of Commerce, Community, and Economic Development Division of Corporations, Business and Professional Licensing PO Box 110806, Juneau, Alaska 99811-0806 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 form to the Division. Completion of this form is not proof of payment until the division processes the information contained herein. If any information on this form is illegible, the form will be rejected. Please print. Name of Applicant or Licensee: ________________________________________________________
Corporate or Individual (first, middle, last)

License Number (if applicable): ________________________________________________________ Type of License: ___________________________________________________________________ I wish to make payment by credit card for the following:
(check all that apply)

Amount __________ __________ __________ __________

Application fee License (or renewal) fee Fine Other (specify): _____________________________

0.00 Total: __________
Print Name on Credit Card: _________________________________________________________ Complete Mailing Address: _________________________________________________________ _________________________________________________________ Telephone Number: _______________________________________________________________ Signature of Credit Card Holder: ___________________________________________________ Credit Card Type (check one): VISA MASTERCARD

Card Number: _______________________________________________________ Please provide the 3-digit security code number from the back of the card: ________ Expiration Date: ________________________

Form 08-4438 (Rev. 03/03/09)