08-4758 Rev 04/01/18 Request for Wall Certificate For Professional Licenses Only Wall certificates are for professional licenses only. Corporations and Business Licensing issue separate certificates. Mail this completed form and payment to the post office box address above. Make checks payable to 223State of Alaska224, or use the attached credit card payment form. Payment must accompany this request. ADM State Office Building, 333 Willoughby Avenue, 9th Floor PO Box 110806, Juneau, AK 99811-0806 Phone: (907) 465-2550 Email: license@alaska.gov Website: ProfessionalLicense.Alaska.Gov Request for Wall Certificate Required Fee: Professional License Wall Certificate $20.00 INFORMATION ABOUT THE PROFESSIONAL LICENSEE: Name: Profession: Address: Phone: Email: Professional License Type: Professional License Number: Signature of Professional License Holder Date FOR DIVISION USE ONLY T HE S TATE ALASKA of Department of Commerce, Community , and Economic Development Division of Corporations, Business and Professional Licensing American LegalNet, Inc. www.FormsWorkFlow.com All major credit cards are accepted. For security purposes, do not email credit card information. Include this credit card payment form with your application. Name of Applicant or Licensee: Program Type: License Number (if applicable): I wish to make payment by credit card for the following (check all that apply): AMOUNT Application Fee: License or Renewal Fee: Other (name change, wall certificate, fine, duplicate license, exam, etc.): 1. 2. TOTAL: Name (as shown on credit card): Mailing Address: Phone Number: Email (optional): Signature of Credit Card Holder: 08-4438 Rev 12/26/18 Credit Card Payment Form (all major cards accepted) State of Alaska Department of Commerce, Community, and Economic Development Division of Corporations, Business and Professional Licensing PO Box 110806, Juneau, AK 99811 Phone: (907) 465-2550 Credit Card Payment Form CREDIT CARD INFO: Your payment cannot be processed unless all fields are completed! All four fields MUST be completed! This section will be destroyed after the payment is processed. 1. Account Number : 2. Expiration Date: 3. Billing ZIP Code: 4 . Security Code : FOR DIVISION USE ONLY T HE S TATE ALASKA of Department of Commerce, Community , and Economic Development Division of Corporations, Business and Professional Licensing American LegalNet, Inc. www.FormsWorkFlow.com