DMS 004 (06/10/2015)
LICENSE, ID CARD AND RECORDS
PAYMENT AUTHORIZATION
Purpose: Customers fax this form to DMV for payment authorization.
Instructions: Do not mail this form. Fax the completed form to the applicable fax number listed in the Transaction/Fax
Information section.
I authorize DMV to charge the credit card account listed.
CARD HOLDER SIGNATURE
DATE (mm/dd/yyyy)
PAYMENT AUTHORIZATION
CREDIT CARD (check one)
VISAMASTERCARD
NAME APPEARING ON CREDIT CARD DAYTIME TELEPHONE NUMBER
AMOUNT TO BE CHARGED
$
AMERICAN
EXPRESS
DISCOVER
CREDIT CARD NUMBER EXPIRATION DATE (mm/yy)
CUSTOMER INFORMATION
NAME DRIVER LICENSE/CUSTOMER NUMBER
MAILING ADDRESS CITY STATE ZIP CODE (required) BIRTH DATE (mm/dd/yyyy)
TRANSACTION/FAX INFORMATION
Identify the applicable work center for the transaction you are completing and fax this completed form to the number provided.
License and ID Work Center
Fax Number: (804) 367-1112
Customer Records Work Center
Fax Number: (804) 367-6710
RENEWAL REPLACEMENT
Driver's License
(include Form DL 1P - Driver's License and
Identification Card Application)
Driving Record - (include Form CRD 93 - Information Request)
RENEWAL REPLACEMENT
CDL License
(include Form DL 1P - Driver's License and
Identification Card Application)
Vehicle Record - (include Form CRD 93 - Information Request)
RENEWAL REPLACEMENT
Identification Card
(include Form DL 1P - Driver's License and
Identification Card Application)
Police Crash Report - (include Form CRD 93 - Information Request)
ORIGINAL REPLACEMENT
Veterans Identification Card
(include DL 11 - Virginia Veterans Identification
Card Application)
