I ALREADY HAVE A PREPASS ACCOUNT NUMBER:
I ALREADY HAVE A TRANSPONDER TRANSPONDER NUMBER:
I WOULD LIKE TO ENROLL IN THE FOLLOWING
(Check all that apply)
PREPASSPREPASS PLUSTOLLS ONLY
AGPASS ONLYAGPASS AND PREPASSAGPASS AND PREPASS PLUS
Contact Information
Contact Name Title
Addresss City State
 Zip Code
Email Address Fax Number

ALL BILLING WILL BE SENT TO
SECURITY CREDIT CORP

Applicant Name (Company or Owner Operator) Leased to: (Company Owning Credentials)
Shipping Information (No P.O. Boxes)
Contact Name Title
Address (No P.O. Box) City State
 Zip Code
Email Address Telephone Number Cell Number Fax Number
Licenses and Permits Information
Contact Name Title
Email Address Telephone Number Fax Number
(Please complete all boxes below - write N/A in boxes that do not apply)
MC/ICC Number U.S. DOT Number CA Number
Carrier Type (Check all that apply)
Common Contract Exempt Intrastate Private Government
Hazardous Materials/Waste Criteria
Are you authorized to haul hazardous materials and/or hazardous waste?
Yes No - Do Not Carry Hazmat / Hazwaste
Please check all applicable boxes.
Hazardous Materials: Dedicated Occasional
Hazardous Waste: Dedicated Occasional
Fuel Tanker: Dedicated  
Are you authorized to haul hazardous materials and/or hazardous waste in the state of West Virginia?
Yes No
If yes, please provide a copy of your "Alliance for Uniform Hazmat Transportation Procedures" License.
Note: If only certain vehicles in your fleet haul Hazardous Materials and/or Hazardous Waste, please notify PrePass.
New Mexico Criteria
Do you have a New Mexico tax ID permit?
Yes No If No, do you: pay per trip
  not travel in NM
Arizona Agriculture Criteria
Any carrier hauling agricultural products in Arizona (See Terms and Conditions for a list of ag products) must report to the Port of Entry, regardless of transponder signal
Are you a dedicated agricultural hauler in Arizona? Yes No (If Yes, you will not be able to bypass in Arizona)
Also, if you pick up loads in certain states, you may be subject to a random pull in for fire ant inspection, regardless of load type.
Do you pick up loads in AL, AR, FL, GA, LA, MS, NC, OK, SC, TN or TX? Yes No
 
I certify that I am authorized to bind the owner operator, company or corporation in whose name this application is made. I have read and reviewed the information on all pages of this application and the License Agreement. By signing below, I indicate my acceptance and consent to the terms and conditions of this application and the License Agreement printed with the application.
Company or Owner Operator Signature
Please use the box below to sign your name:
Print Name and Title:
Date: 02/07/2012