Fillable Printable Credit Card Authorization Form - Alaska

Credit Card Authorization Form - Alaska

Form 610 (Rev 02/25/2014) Credit Card Authorization Form

State of Alaska

Division of Motor Vehicles

Credit Card Authorization Form by Fax

Driver license records are confidential; therefore, you may only obtain your personal record, unless you have a

signed release to obtain a record for another person per AS 28.10.505. Please call (907) 465-4361 option #2

for questions regarding this form or the reinstate process.

Please check credit card type: Visa MasterCard

Credit card number: ________/________/________/________ Visa Card only - VIN Code:

Expiration Date: _______/_______ (mm/yy)

Name as it appears on the credit card: __________________________________________________________

Please check the following that apply:

Reinstatement fee: $___________

Other: Explain _________________________________ $___________

_________________________________

Total amount to be charged: $ ___________

Daytime Phone Number: ____________________

Cardholder Signature: _________________________________________ Date: _____________________

Name as it appears on Driver’s License: _________________________________________________________

Record/Driver license number: __________________________________________________________

OR Date of Birth: ______/______/__________ AND SSN: ______/_____/_________

mm dd yyyy

The Record Holder/Driver may request a clearance letter by completing a Driving Record Request (Form 419F)

and sending along with this Credit Card Authorization Form. There is a $10 additional fee for a clearance

letter.

FAX FORM TO: 1-907-465-5509

MAIL: Division of Motor Vehicles

PO Box 110221

Allow 3 business days for processing. Juneau, AK 99811-0221

CREDIT CARD HOLDER INFORMATION

RECORD/DRIVER INFORMATION