Credit Card Payment Form

State of Alaska, Department of Commerce, Community, and Economic Development Division of Banking and SecuritiesPO Box 110807, Juneau, AK 99811-0807Fax 907-465-1230 Name: Company: Industry: Other (specify) Total: Visa MasterCardDiscoverAmEx CVC: For security purposes, do not email credit card information. This form accepted by FAX ONLY. 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 not be processed. Alaska Credit Card Payment Form License # (if applicable): I wish to make payment by credit card for the following (check all that apply): Amount Application Fee License or Renewal Fee Fine (case/order #) ANCSA Fee Credit Card Type: Printed Name on Card: Credit Card Billing Address: Contact Telephone Number: Contact Email: Expiration Date: Signature of Card Holder: The bottom section of this form will be destroyed upon processing of the payment. Card Number: Rev. American LegalNet, Inc. www.FormsWorkFlow.com