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
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Credit Card Authorization Form - Alaska PDF

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