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Txtag Enrollment Form: I. Customer Information

This TxTag enrollment form allows customers to provide their contact and payment information to open an account. It requests the customer's name, address, phone numbers, email, and preferred PIN. It also asks the customer to select a statement delivery method of email, mail, or no statement. For payment, customers can select to pay by credit card on a one-time or auto-pay basis, by check, or cash in person. The form finishes by having the customer provide license plate, state, year, make, model, and color for each vehicle to be linked to the new TxTag account.

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Yaniss Maracuya
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38 views1 page

Txtag Enrollment Form: I. Customer Information

This TxTag enrollment form allows customers to provide their contact and payment information to open an account. It requests the customer's name, address, phone numbers, email, and preferred PIN. It also asks the customer to select a statement delivery method of email, mail, or no statement. For payment, customers can select to pay by credit card on a one-time or auto-pay basis, by check, or cash in person. The form finishes by having the customer provide license plate, state, year, make, model, and color for each vehicle to be linked to the new TxTag account.

Uploaded by

Yaniss Maracuya
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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TxTag 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:
Office Use Only: Acct. No: ______________________________________ Opened by: __________________________________________

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