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.

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: _____________________

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