Txtag Enrollment Form
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1TxTag Enrollment Form
I. CUSTOMER INFORMATION
(Please print clearly)
Last Name: ____________________________________________________
First Name: _________________________________________
Mailing Address: _____________________________________________________________________________________________________
City: __________________________________________________________
State: _______
Zip Code: ____________________________
Work Phone: ___________________________
Home Phone: _______________________ Fax: _________________________________
Email Address: _______________________________________________________________________________________________________
Preferred PIN:
(This number will be used to access your account online)
Statement Delivery Method: (Please check one)
£ Email (free)
£ Mail ($1.15 fee)
£ No Statement Delivered (available online)
II. PAYMENT OPTIONS
(Please check one)
£ Credit Card: Auto Pay
Amount: ________________
I authorize Tx DOT to bill a credit card for initial payment to my Tx Tag account and to automatically bill the credit card periodically to
replenish my TxTag account in accordance with the TxTag License and Use Agreement.
£ Credit Card: One-Time Payment
Amount: ________________
I authorize Tx DOT to bill a credit card for initial payment in accordance with the TxTag License and Use Agreement.
£ VISA
£ MasterCard
£ Discover
£ American Express
Cardholder’s Name: _______________________________________________________________________________________________
Credit Card Number: ____________________________________________________
Expiration Date: __________________________
Cardholder’s Signature: ___________________________________________________________ Date: __________________________
£ Check:
Check Number: ________________ Amount: ________________
Please make checks payable to TxTag CSC.
£ Cash:
Amount: ________________
To make a cash payment, visit the TxTag Customer Service Center at: 12719 Burnet Road, Austin, TX 78727. Do not mail cash.
III. VEHICLE INFORMATION
(A tag will be provided for each vehicle listed)
License Plate No.
State
Year
Make
Model
Color
RETURN ENROLLMENT FORM bY MAIL, FAx OR ONLINE
+
Mail: TxTag CSC, 12719 Burnet Road, Austin, TX 78727
7
Fax:
214-210-0492
Office Use Only:
Acct. No: _____________________________________
Opened by: _________________________________________
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