MCP Application

Vehicle(s)

Total Price

Cardholder’s Name

Card Number

Card Expiration Date

Card CVC Number

Current Balance

•••• •••• •••• ••••

MM/YY

Billing Address

Address

City

Country

State/Province

Postal Code

Same as physical address Same as mailing address New address

Initials

I certify that I am the authorized holder and signer of the credit card referenced above. I certify that all the information above is complete and accurate.

I understand that the information input is correct to my knowledge. Submitting false information could result in penalties and fines. It is a federal crime to submit false information in an attempt to commit fraud.

I hereby authorize the collection of payment to DOT Operating Authority Inc., (DBA) Motor Carrier Permits Services, for all charges as indicated above. I acknowledge that charges to my provided payment method may not exceed the total amount listed under the “TOTAL PRICE” field. I understand that I am responsible for the full amount listed in the “TOTAL PRICE” field. I understand that this authorization is only in effect during the time period of this transaction. If any additional charges are to need authorization, a new authorization form will have to be completed.

I acknowledge that the total amount of today’s transaction, indicated under the “TOTAL PRICE” field includes any and all Federal, State, and Local Government fees.

I hereby acknowledge and agree that after the charges are authorized, a DOT Operating Authority Inc., (DBA) Motor Carrier Permits Services agent will be assigned within 15 minutes to complete the order. Once the agent has been assigned, the payment cannot be cancelled, and the charges are non-refundable. DOT Operating Authority Inc., (DBA) Motor Carrier Permits Services, does not accept any responsibility for refusal or reversal of payments, which shall be a matter between you and your credit card issuer.

I want to receive important email and text notifications about my order, and renewal reminders.

I want to receive emails and messages for marketing and exclusive updates from Motor Carrier Permits Services.

I accept the Terms of Service & Privacy Policy

By providing your phone number, you consent to receive informational text messages from MotorCarrierPermit.com. Your consent is not a condition of purchase. Message frequency may vary. Standard message and data rates may apply. Reply HELP for assistance or STOP to unsubscribe.

Name of Person Signing

Date signed

Signature