Epass Fm Csd 019 Form – Fill Out and Use This PDF

This serves as my Authorization to the E-Pass Official Credit Card Merchant, Citra Metro Manila Tollways Corporation (“CMMTC”), with the Provider of the E-Pass Services, Skyway O & M Corporation or its assignee (“Provider”), to charge my Credit Card for the replenishment of my E-Pass Account in accordance with the selected mode and the credit card information as provided below:

AUTOMATIC REPLENISHMENT

Automatic Replenishment Amount (Select 1 only)

P 1,000.00

P 1,500.00

P 2,000.00

P

Other amount higher than P 2,000.00

Upon selecting Automatic Replenishment, I hereby authorize CMMTC and/or the Provider to debit the authorized replenishment amount I selected above whenever my E-Pass account balance amounts to P500.00 or below.

MANUAL REPLENISHMENT

Upon selecting Manual Replenishment, I agree to call the E-Pass Replenishment Hotline number (888- 8787) to replenish my E-Pass account with amounts sufficient to always allow my registered vehicle continuous use of the E-Pass Lanes.

CREDIT CARD INFORMATION

16-digit Credit Card #

Expiry Date MM

YYYY

VISA

MC

Diners

Amex

JCB

16-DIGIT E-PASS ACCOUNT NUMBER

and/or

10-DIGIT E-PASS TAG SERIAL NUMBER

1.I understand that this Authorization shall not be processed by the Provider if this form has not been completely filled-up, and/or if all the information and all the documents required by the Provider have not been submitted. I shall inform the Provider in writing of any change in my Credit Card account (such as account number and expiry date) issued by my bank, __________________________(“Issuer Bank”), and submit the related documents (e.g., photocopy of the new credit card) as may be required by the Provider, at least fifteen (15) calendar days before the effective date of such change. I shall also inform the Provider in writing in case of loss or expiration of my Credit Card, which shall automatically cancel this Authorization.

2.I shall hold CMMTC and/or the Provider, as well as their affiliates, and their directors, shareholders, officers, employees, agents and representatives, free and harmless from any liability or responsibility in connection with (i) any change in my Credit Card account which has not been timely disclosed to the Provider; (ii) any dispute arising between myself and the Issuer Bank, including but not limited to issues on any surcharge, interest, penalty or any other charges or fees billed to me by the Issuer Bank; and (iii) any claim for loss or damages arising out of or in relation to force majeure and other circumstances beyond their reasonable control, including the refusal by the Issuer Bank to honor the E-Pass Account replenishment for any reason whatsoever.

3.I shall communicate directly with the Issuer Bank on any and all matters involving disputes or questions I may have on the E-Pass Account replenishment billings as seen in my credit card Statement of Account.

4.I understand that, as a matter of practice, the Issuer Bank does not deal directly with its Merchants such as CMMTC and/or the Provider on matters stated in Section 3 above.

5.I understand that the Issuer Bank has set a period of sixty (60) calendar days from the date of an E-Pass Account replenishment within which I may notify the said Issuer Bank and the Provider if I have a dispute or concern with the said replenishment. I hereby confirm and agree that if I have not disputed an E-Pass Account replenishment within the said (60) sixty day period, I have considered such E-Pass Account replenishment to be valid and in good order.

6.I understand and agree that only the available credit limit in my Credit Card account shall be utilized for the E-Pass Account replenishment. If the E-Pass Account replenishment was not made due to insufficient balance or any problem in, or termination/cancellation of, my Credit Card account or for other reasons, I shall be responsible for the timely replenishment of my E-Pass Account through other modes of replenishment in order to continue to avail of the E-Pass Services.

7.I understand and agree that in case of recurrent failures in the replenishment of my E-Pass Account due to insufficiency of funds in my Credit Card account or any problem related thereto, the Provider may cancel this Authorization without prior notice to me.

8.This Authorization shall take effect upon the approval of the Provider and until (i) the termination or expiration of the Contract; (ii) the cancellation of this Authorization by the Provider due to recurrent failures in the replenishment of my E-Pass Account pursuant to Section 7 above; (iii) the receipt by the Provider of my written notice of loss of my Credit Card pursuant to Section 1 above; or (iv) after thirty (30) days from the receipt by the Provider of my written notice of cancellation of this Authorization.

Unless otherwise stated herein or the context otherwise requires, capitalized terms used herein shall have the same meaning as ascribed in my Contract for E-Pass Services with the Provider (“Contract”).

In line with this Authorization made in relation to the Contract, which shall form an integral part hereof, I hereby agree to the following terms and conditions:

Contact Information:
O f f i c e A d d re s s	: C a p sto n e Te c h n o l o g i e s , I n c .
	Skyway Building , Doña Sogchnololedad Avenue
	Better Living Subdivision, 1700 Parañaque City
E - M a i l A d d re s s :	: c u sto m e rca re @ e p a s s . c o m . p h
C S C H o t l i n e	: (02) 888-8787

Printed Name and Signature of Credit: Card Holder:

Date	: MM				DD					YYYY
Requirements:	Photocopy of latest Credit Card SOA/Billing
	Photocopy of Credit Card (front and back)

Customer Care Business Hours:

Mondays to Fridays 8:00 a.m. to 8:00 p.m.

Saturdays