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) DOT Number Texas, 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 COST” field. I understand that I am responsible for the
full amount listed in the “TOTAL COST” 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 COST” 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) DOT Number
Texas 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) DOT Number Texas does not accept any
responsibility for refusal or reversal of payments, which shall
be a matter between you and your credit card issuer.