Register for a Dart Charge Account Did you know you can register online at www.gov.uk/dartcharge * Information that must be provided 1. About you Title Mr Mrs Ms Miss Other First Name* Middle Name Last Name* House number and street* Town/ City* County Postcode* Country* Contact phone number* Email Address How would you like us to contact you?* By Email By Post Once your account has been opened, we will send you a welcome pack containing all of the necessary documentation 2. Vehicle details Please use this section to tell us about the vehicles you would like to register for Dart Charge. We will calculate your Dart Charge based on the information supplied below. Vehicle 1 Vehicle Registration Mark (Number plate) Make (e.g Ford) Model (e.g Focus) Colour Please tick if you would like to receive a Dart Charge Tag for this vehicle Please select the vehicle class; Class B: Car Class C: 2 Axle Goods Class D: Multi Axle Goods Vehicle 2 Vehicle Registration Mark (Number plate) Make (e.g Ford) Model (e.g Focus) Colour Please tick if you would like to receive a Dart Charge Tag for this vehicle Please select the vehicle class; Class B: Car Class C: 2 Axle Goods Class D: Multi Axle Goods Vehicle 3 Vehicle Registration Mark (Number plate) Make (e.g Ford) Model (e.g Focus) Colour Please tick if you would like to receive a Dart Charge Tag for this vehicle Please select the vehicle class; Class B: Car Class C: 2 Axle Goods Class D: Multi Axle Goods Please confirm that you own the vehicle(s) above or have the permission of the vehicle owner to register and receive information about their vehicle on their behalf 3. Payment details To open a Dart Charge account a minimum payment of £10 is required. Dart Charge will deduct this payment upon account creation. You can also use this form to set up AutoPay. With AutoPay your account can topup automatically by recurring direct debit or card payment. Please choose one* of the following: Set your Dart Charge account up for AutoPay using Direct Debit. Go to attached Direct Debit mandate form. Set your Dart Charge account up for AutoPay using a payment card Go to Section 3.1 Just pay £10 to create a Dart Charge account and manually topup when required Go to Section 3.2 3.1 Set your Dart Charge account up for AutoPay using a payment card When your CC autopay is active we will deduct the initial £10 payment automatically. Once your account balance reaches the low balance threshold of £10 we will deduct a payment from your card based on your chosen top up amount. Top up amount £ * Minimum top up amount is £10 Please tick one* of the following: Visa MasterCard Amex Maestro Name on Card * Card Number * Expiry date * Valid from MM/YY CVV By signing the box below I authorise Dart Charge to charge my payment card with the amount shown in the Total Payment Box Above By signing the box below you are confirming you are the cardholder and that you authorise Dart Charge as and when they become due for the purposes of Auto Pay from the payment card specified above. Signature * Date * DD/MM/YYYY 3.2 Pay £10 to create a Dart Charge account and manually top , up when required Please tick one * of the following: I am enclosing a cheque/ postal order for £10. Cheques or postal orders should be made payable to Dart Charge OR I authorise you to debit my credit/ debit card for the above amount, by; Visa MasterCard Amex Maestro Name on Card * Card Number * Expiry date * Valid from MM/YY CVV* 4. Declaration Please read the following declaration very carefully. By signing this form, I certify that the details given on this form are to the best of my knowledge true and correct. I understand that filing a false declaration knowingly and wilfully is a criminal offence for which I may be prosecuted. By signing this form I understand that I must allow 10 days processing time prior to my account opening. Dart Charge cannot be held responsible for postal delays. If I do not allow adequate processing time for the charge to be applied, Penalty Charge Notices may be issued to the registered keeper of the vehicle for which they are liable. By signing this form, I confirm that I have read and fully understand the terms and conditions associated with having a Dart Charge account. I confirm that I have read and that I understand the above declaration Signature * Date * DD/MM/YYYY A full copy of the Dart Charge Terms and Conditions can be found on gov.uk/dartcharge or you request a copy by phone on 0300 3000 120. 5. Cancellation You have the right to cancel this Agreement at any time within 14 days beginning on the day after the contract is formed. If you wish to cancel, you simply need to tell us. You can tell us by phone on 0300 3000 120, by writing to Dart Charge, PO Box 842, Leeds, LS1 9QF or by using the cancellation form which you can find at www.gov.uk/dartcharge or in your Welcome Pack. You may terminate this Agreement on 30 days' notice to us either in writing, by telephone or online via the Website. I request that my account is opened and activated prior to the expiry of the 14 day cancellation period to which I am entitled. I acknowledge that by activating the account early, I am under an obligation to pay for any charges and other account services provided up until cancellation should I subsequently exercise my right to cancel. Finally Please send this form with your Dart Charge payment to: Dart Charge, PO Box 842, Leeds, LS1 9QF Ensure that you pay the correct postage when sending your application form to us. You may be charged if insufficient postage is paid. We may do this by deducting the amount of postage from your account credit About Dart Charge We are the Secretary of State for Transport of Great Minster House, 33 Horseferry Road, London, SW1P 4DR. The Accounts, Local Residents’ Discount Scheme, Tags and website are operated on our behalf by Sanef Operations Limited as our agent (company number 8703645, registered in England and Wales, with registered office at ST John's Offices, Albion Street, Leeds, LS2 8LQ (VAT number GB174301040).
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