June 2015

FasTrak® Customer Service Center PO Box 26926 San Francisco, CA 94126 www.bayareafastrak.org 1-877-BAY-TOLL (1-877-229-8655)Fax: 1-415-974-6356International: 1-415-486-8655

Account Application

1. Account Information Please Print or Type

Account Number __________________ or Tag Number _____________________________First Name __________________________ Last Name ______________________________ Business Name (if any) ________________________________________________________ Mailing Address _____________________________________________________________City _______________________________ State ________ Zip Code __________________ Day Phone _________________________ Evening Phone ___________________________Email Address _______________________________________________________________

2. Tag Order Select Type and Number

Total # Toll Tags ______ Toll Tag ______ Used for traveling on express lanes and bridges.

CAV Toll Tag ______Eligible Clean Air Vehicles are required to use CAV toll tags on SR-237 express lanes, a copy of your DMV issued Decal certificate must be attached to your application. See website for more info.

3. Account Payment Options Select a Payment OptionA refundable security deposit per tag is required for each toll tag. If you choose to the Credit Card Option, thesecurity deposit will be waived for the first three tags on the account.

Cash or Check Option Add funds to your account using cash or checks.

Make check payable to BATA. Mail payment with this form tothe above address.

Do not send cash in the mail. Call the CSC to receiveinstructions on how to pay with cash.

Credit Card Option Add funds to your account using a credit card.

Select One:

Visa MasterCard Discover American Express

Credit Card Number Exp. Date (MMYY)

Signature (Required for Credit Card Payment)

4. Vehicle Information Add vehicles authorized to use your FasTrak account.

License Plate and State of Registration are required. You may back date the start date up to 90 days, but will beassuming liability for any tolls or penalties associated with the vehicle during the effective time period.

1

License Plate State Make Model Year Effective Start Date

Tags on account over 3$20 each tag over 3

Total # tags _______

$20 per tag

Toll Tag Request

I authorize payment to my credit card for the total amount due.

Total Now Due

Total Now Due

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http://www.bayareafastrak.org/

First Name: Last Name: Business Name if any: Mailing Address: City: State: Zip Code: Day Phone: Evening Phone: Email Address: Standard: Exterior: FasTrak Flex: Total tags: 1: Exp Date MMYY: License PlateRow1: StateRow1: MakeRow1: ModelRow1: YearRow1: Effective Start DateRow1: License PlateRow2: StateRow2: MakeRow2: ModelRow2: YearRow2: Effective Start DateRow2: License PlateRow3: StateRow3: MakeRow3: ModelRow3: YearRow3: Effective Start DateRow3: Account Number: tag Number: Check Box1: OffCheck Box2: OffDiscover: OffDigit 1: 2: 3: 4: 5: 6: MC: OffAmex: OffVisa: Off