New Customer Application

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Customer Application and Agreement
Company Type*
- Sole Proprietorship
- Partnership
- Corporation
- S-Corp
Legal Company Name(s):*
DBA:
Contact Name:*
First Last
Billing Contact:*
First Last
Company Phone:*
Mobile Phone:
Fax:
E-Mail:*
Company Physical Address:*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
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Signature Of Name Of Credit Card
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Consent
I understand that Permit America will Pre-Authorize my credit card upon ordering permits. I understand that this Pre-Authorization will be removed from my billing statement within 72 hours upon completion of my invoice. My credit card will then be charged for the full amount of the invoice, including a 4% convenience fee. I hereby authorize Permit America to charge my credit card account.
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Date
MM slash DD slash YYYY

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STATE AUTHORITY INFORMATION
Delaware #:
Oregon #:
KYU Authority #:
Texas #:
Louisiana O/D #:
Virginia #:
New York #:
Wisconsin #:
Alberta #:
Canada CVOR #:
Canada NIC #:

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ID/OPERATIONS
EIN, FIN, TIN, Or SSN:*
USDOT #:*
MC/MX/FF Number(s):
IFTA #:
IRP #:
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INSURANCE INFORMATION
Insurance Company Name:
Policy Number:
Expiration Date:
MM slash DD slash YYYY

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BILLING INFORMATION (AS IT APPEARS ON YOUR CREDIT CARD STATEMENT)
Your security is important to us. All information entered on this form will be kept strictly confidential. We do not share credit card information and our payment process is PCI compliant which ensures that your information is being handled in accordance with industry security standards. For more information on PCI compliance please click the PCI icon on the right of your screen. You may cancel this authorization at any time by contacting Permit America, Inc at (866) 573-7648; this authorization will remain in effect until cancelled by you.
Credit Card Number*
Expiration Date*
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CVW
Address On Credit Card Statement:*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Name on displayed on card*
First Last

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Permit Cancellations:
It is the policy of Permit America to attempt to cancel permits immediately upon the customer's request.
Note: Cancellation of permits is ultimately decided by the Agency issuing the permit and not all cancellation requests are honored or guaranteed by the Agency. Customers are responsible for permit cost that are denied cancellation by the Agency(s), and all applicable fees.

Placement of an order on Permit America, Inc. by the purchases shall be deemed as acceptance of Permit America's terms and conditions. Orders are accepted to the purchaser's account being current and within its credit limit.
Billing Procedures:
Permit America, the above applicant and any subsidiaries of the same, hereafter referred to as Client, do hereby authorize Permit America to act as the Client’s agent, empowering Permit America to purchase OD/OW permits and related items from authorized federal, state, and local transportation offices. Client assumes full financial obligation for all OD/OW permits ordered through Permit America and associated service fees billed by Permit America. Client assumes full responsibility for accuracy of permits once received from Permit America. Client will receive invoices from Permit America itemizing all transactions which will include the appropriate billing names/numbers as directed by the Client. Client’s credit card will be billed for permits and services. A four (4%) convenience fee will be added for all credit card orders.

Once a client has established credit with Permit America they may be moved to an invoiced account, if requested in writing and approved by Permit America’s CFO. Client agrees to Permit America’s terms of net fifteen (15) days. Payment is due 15 days from date of invoice. Invoices that have not been paid in full within thirty (30) days of the invoice date may incur a late fee of two percent (2%) of in invoice total, or a twenty-five dollar ($25) flat fee, whichever is greater. Permit America reserves the right to charge Client’s credit card for unpaid invoices even after Client is moved to an invoiced account. Permit America reserves the right to cancel any account, permit, or other service with or without notice, In the event the Client’s account is in arrears. Client agrees to indemnify Permit America for any losses, claims, liability, or damages including reasonable attorney’s fees and/ or collection fees arising out of or resulting from actions taken by Permit America in order to settle an overdue account.

Termination:
This agreement may be terminated by either party, at any time, with or without cause. However, both parties are bound by terms stipulated herein for all services and OD/OW permits ordered for the Client by Permit America prior to termination. All open invoices are due in full upon termination and will be charged interest at two percent (2%) of account total, or twenty-five dollar ($25) flat fee per invoice, whichever is greater, starting one (1) day after termination.

Binding:
This Agreement shall ensure the benefit of, and be binding on, the parties hereto and their respective successors and permitted assigns.

Laws:
This Agreement shall be governed by, and interpreted in accordance, with the laws of the Commonwealth of Kentucky.
Hold Harmless Agreement: The Applicant agrees that for Permit America, Inc. to obtain correct permits, the Applicant must submit to Permit America, Inc. the correct information. Thus, in the event Permit America obtains a permit (or permits) for the Applicant which is based upon incorrect information provided by the Applicant, and if any claim is filed against Permit America, Inc. as a result of Permit America, Inc. obtaining the permit (or permits), then the Applicant agrees to indemnify and hold harmless Permit America, Inc., and any related companies, their agents, representatives, heirs, successors, and assigns, against any and all loss or losses as a result of claims, demands, obligations, actions, causes of action, damages, attorney's fees, cost, and/or expenses arising out of obtaining their permit (or permits). The individual signing below certifies he/she has the authority to bind the Applicant to this provision.
Consent*
I understand that Permit America will Pre-Authorize my credit card upon ordering permits. I understand that this Pre-Authorization will be removed from my billing statement within 72 hours upon completion of my invoice. My credit card will then be charged for the full amount of the invoice, including a 4% convenience fee. I hereby authorize Permit America to charge my credit card account. I agree and accept the terms as stated above.
Authorization Name:*
First Last
Authorization Signature:*
Signature Date*
MM slash DD slash YYYY
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Phone
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Customer Application and Agreement

STATE AUTHORITY INFORMATION

ID/OPERATIONS

INSURANCE INFORMATION

Carrier Questionnaire

NOTICE

BILLING INFORMATION (AS IT APPEARS ON YOUR CREDIT CARD STATEMENT)

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