Contact Person: Last Name First Name

Email Address (Will help you access your account online)

SUNPASS PLUS AIRPORT PARKING

PREPAID ACCOUNT REPLENISHMENT OPTIONSTRANSPONDER PURCHASE

Please select Option A or B indicating your payment method.

OPTION A: CHECK OR MONEY ORDER

www.SunPass.com

SUNPASS® COMMERCIAL ACCOUNT APPLICATION

COMPANY INFORMATION

Company Name

Street Address Apt.#

City County State Zip Code

$ Check/Money Order Number Amount

(Please make checks payable to Florida Department of Transportation.)

SUBMIT YOUR COMPLETED APPLICATION TO:

OPTION A: IN PERSON OR BY MAIL (select one)Note: 30 days of average toll usage is the recommended replenishment amount.

OPTION C: AUTOMATIC CREDIT/DEBIT CARD REPLENISHMENT

Please check one: VISA MASTERCARD DISCOVER AMEX

Low Balance Threshold: $ ________________________________

Automatic Replenishment Amount (Minimum $10.00): $ ________________________________

Credit/Debit Card Number

Authorized Signature Date

Expiration Date

OPTION B: WWW.SUNPASS.COM OR PHONE

10/2014

SunPass PORTABLE can be purchased for $19.99 plus applicable sales tax. SunPass MINI can be purchased for $4.99 plus applicable sales tax. A minimum initial prepaid balance of $50.00 is required to pay for your initial toll usage.

*Sales tax rates are to include Florida state sales tax of 6.00% plus county discretionary sales tax for the county listed under “Company Information” above. Please verify the sales tax rate for your county at: http://dor.my�orida.com/dor/forms/current/dr15dss_1113.pdf

**The SunPass Program will monitor your account’s activity and may adjust the required account balance or low balance amount on actual usage.

PERSONAL IDENTIFICATION NUMBER

Please enter a 4-digit (numeric) number in the box provided. You will need this number to verify your identity when requesting account information.

The SunPass Program several convenient methods to replenish your Prepaid Account. Please select a replenishment option of your choice from the following methods:

This option authorizes the SunPass Program to automatically replenish your Prepaid Account by charging your card whenever your account drops to the low balance threshold you provide below.Note: The low balance threshold is the balance your account must reach before it is replenished automatically. 15 days of average toll usage is the recommended low balance threshhold.

Authorization: I hereby authorize the SunPass Program to charge my credit card in the amount indicated above whenever my Prepaid Account drops to my chosen low balance threshold. I understand this

This option allows you to replenish your Prepaid Account with a major credit card online at www.SunPass.com.

You may also replenish using our automated phone system or by speaking with a customer service representative at 1-888-TOLL-FLA (1-888-865-5352).

Check this box if you DO NOT want to enjoy the speed and convenience of using your transponders to pay for parking at Miami, Orlando, Ft. Lauderdale, Tampa and Palm Beach International airports. To be a SunPass Plus customer, you must sign up for SunPass® Easy Pay auto replenishment using a credit card.

Phone Number Extension Number

Authorized Signature: Date:

I hereby agree to use the SunPass System in accordance with the terms and conditions of the SunPass Customer Agreement. I understand that my SunPass transponder must be properly mounted on the inside of the vehicle’s windshield. The transponder will allow passage on all SunPass-equipped toll facilities and that the toll charges will be deducted from my SunPass Prepaid Account. If I do not agree with the stated terms and conditions of the Agreement, I will return my SunPass Transponder within 45 days for a refund.

New Enrollments - Commercial AccountsSunPass Prepaid Toll ProgramPO Box 880029Boca Raton, Florida 33488-0029Fax: 1-888-265-1725

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

SunPass PORTABLE Transponders ordered ___________ @ $19.99 each

SunPass MINI Transponders ordered ___________ @ $4.99 each

TAXABLE SUBTOTAL

PLUS Florida sales tax for your county*

PLUS Initial Prepaid Account Balance - A minimum initial prepaid balance of $50.00 is required.**

TOTAL ENCLOSED FOR TRANSPONDER PURCHASE

+

+

+

CUSTOMER AGREEMENT

OPTION B: CREDIT/DEBIT CARD

Please check one: VISA MASTERCARD DISCOVER AMEX

Credit/Debit Card Number Expiration Date

Authorized Signature Date

I prefer to replenish my Prepaid Account in person with cash at an authorized SunPassPayment Center. (Visit www.sunpass.com/cash for locations throughout the state of Florida).No credit card needed.

I prefer to replenish my Prepaid Account in person with cash, check or money order at aSunPass Customer Service Center or by mailing payment to SunPass Prepaid TollProgram, P.O. Box 880049, Boca Raton, Florida 33488-0049. (Visit www.sunpass.com/contactSunPass for Service Center locations)

www.SunPass.com

SUNPASS® COMMERCIAL ACCOUNT APPLICATION

8/2012

Instructions: Please enter company name and all vehicles that will be authorized to utilize your SunPass Account. If you need additional sheets, please make additional copies as needed. This form must be �lled out completely and returned with your SunPass application.

Company Name:

Authorized Signature:

Printed Name:

Phone Number:

Date:

Title:

Make/Model Color Year AxleState or Vehicle #License Plate #

AUTHORIZED VEHICLES