EZ TAG Account Authorization Form
____________________________________________________________________________
(To designate Authorized Contact (s) and establish Personal Access Codes)
Please note that all authorized contacts listed on an account must have a Personal Access Code consisting of a combination of 6 to 12 alpha and numeric characters. Existing Account Holders have the option to designate an Authorized Contact (s) at any time after the account was opened. In the event there is no Authorized Contact listed on the account, only the Account Holder is authorized to communicate with Harris County Toll Road Authority.
Account Holder Information:
Account Number: ___________________
Account Holder’s Name: __________________________
Account Holder’s Driver’s License Number: _____________________
Contact Information: E-mail: ___________________Telephone: ________________
Personal Access Code: ___________________
(If choosing a Personal Access Code for the Account Holder complete top portion only)
Authorized Contact (s) Information:
The undersigned Account Holder appoints and designates the following person(s) (Authorized Contact(s)) as the Account Holder’s agent and representative with regard to the above referenced EZ TAG Account:
Name: ________________________________________ Access Code: _______________
Name: ________________________________________ Access Code: _______________
Name: ________________________________________ Access Code: _______________
Name: ________________________________________ Access Code: _______________
Name: ________________________________________ Access Code: _______________
The Authorized Contact is hereby authorized by the Account Holder to communicate with Harris County on behalf of the Account Holder with respect to the account. The Authorized Contact is authorized to make revisions and updates to the account (including but not limited to revisions to the account address, telephone number, vehicle information); and to make credit card updates; substitute or change credit cards. The Authorized Contact may also request additional tags; report tags lost or stolen; add or remove vehicles; request and obtain monthly statements; and review and dispute statements. The Authorized Contact is authorized to manage the EZ TAG Account in all respects, as the Account Holder would be authorized, except that the Authorized Contact is not authorized to change the name or driver’s license number on the EZ TAG Account, add other persons to the account, or close the account.
The Account Holder hereby authorizes and consents to disclose to the Authorized Contact the Account Holder’s personal and confidential information, including address, telephone number, financial information, credit card information, driver’s license number and information, e-mail address, and such other information as is necessary to permit the Authorized Contact to deal with the account in the manner authorized by this designation.
Harris County is authorized to act on all orders, instructions, and requests of the Authorized Contact that are consistent with this designation, and shall not be obligated to communicate with or obtain the prior approval of the Account Holder. The Account Holder hereby releases and discharges Harris County from any and all liability whatsoever for any damages, claims, demands, or causes of action that may result or arise from orders, instructions, or requests communicated to Harris County by the Authorized Contact. The Account Holder agrees to indemnify and hold Harris County harmless from any such damages, claims, demands, and causes of action.
Signature: ____________________________________Date: _________
Printed Name: ________________________________
_________________________________________________________________________________________________________
1/15/2010 |
EZ TAG Account Authorization Form |
FM0184 |
