Application for a Dart Charge Pre-Pay AccountPlease write clearly and in CAPITALS. You may find it quicker and easier to apply online at www.gov.uk/dart-charge, click Start now and select Set up an account. You will need to make a minimum payment of £10, which will be added as credit to your account.

1. About YouTitle*

First Name*

Last Name*

Property number and street*

Town / City*

Postcode*

Contact phone number*

Email address*

Dart Charge emails are sent from donotreply@dartford-crossing-charge.service.gov.uk. Add this email address to your safe senders list to avoid these being marked as spam.

If you require statements ‘By Post’, you are agreeing to pay an additional administration charge of £2 that will be deducted from your Dart Charge account balance every calendar month. The statement will be sent to the address provided above.Tick Box to Confirm By Post

*Information must be provided

Ms Miss OtherMrsMr

2. Vehicle DetailsWe use automatic number plate recognition cameras and electronic tags to record details of all vehicles using the crossing. For more information about electronic tags and how to obtain one, please call Dart Charge Customer Services on 0300 300 0120.

You can add up to 3 vehicles using this application form. If you would like to add more than 3 vehicles, this can be done by logging in online once your account is set up or alternatively call the Contact Centre on 0300 300 0120.

Crossing Charges rates for a vehicle on an account:

Vehicle 1:

Vehicle Registration Mark (Number Plate)

Please select the vehicle class;

Make (e.g. Ford) Model (e.g. Mondeo)

Colour Country

Class B Class C Class D

Vehicle 2:

Please select the vehicle class;

Vehicle Registration Mark (Number Plate)

Make (e.g. Ford)

Colour

Model (e.g. Mondeo)

Country

Class B Class C Class D

Vehicle 3:

Please select the vehicle class;

Vehicle Registration Mark (Number Plate)

Make (e.g. Ford)

Colour

Model (e.g. Mondeo)

Country

Class B Class C Class D

Tick to confirm that you own the vehicle(s) above or have the permission of the vehicle owner to register and receive information about the vehicle on their behalf.

Class Standard

Rate

Account Holder

Discounted Rate (up to 22:00 on 30/9/18)

Account Holder

Discounted Rate (from 06:00 on 1/10/18)

A - Motorcycles, mopeds and quad bikes £0.00 £0.00 £0.00

B - Cars (including trailers), motorhomes and

minibuses (with 9 or less seats including the driver’s

seat)

£2.50 £1.67 £2.00

C - Vehicles with 2 axles £3.00 £2.63 £2.63

D - Vehicles with more than 2 axles £6.00 £5.19 £5.19

3. Adding Credit To Your AccountWe will notify you to let you know when your account is open. Please make other payment arrangements for crossings made before this confirmation.

I am enclosing a cheque / postal order for a minimum of £10. Cheques or postal orders should be made payable to Dart Charge.

4. Topping Up Your AccountThere are 2 top up options, please choose one from the following:

Auto-Top-UpNo need to remember to top-up, complete the Direct Debit Mandate included and funds will be added to your account automatically when the balance falls below your specified amount. Your account will be closed if it falls below £0.00. To manage the credit on your account, you must tell us the minimum balance you wish to maintain and how much you want to top-up by. Consider the frequency of crossing and number of vehicles to calculate this.

Top-up when my balance is

Top-up my account by

Minimum £10

Minimum £10

I have completed the Direct Debit Mandate included with this form.

If you wish to set up Auto-Top-Up by payment card, please contact Dart Charge Customer Services on 0300 300 0120.

Or

Manual Top-up

You must maintain a credit balance balance at all times.You can top up your account balance online at www.dart-charge.gov.uk and select sign in online or by calling our Contact Centre on 0300 300 0120.

If your account balance falls below £0.00, your account will be closed, and you may receive penalty charge notices (PCNs).

5. DeclarationBy signing this form, I confirm that I wish to apply for a Dart Charge account. I also confirm that the details given on this form are, to the best of my knowledge, true and correct.

I understand that I must allow 10 working days for Dart Charge to process this application and that if I use the crossing before this application is processed, I must make alternative arrangements to pay the crossing charge(s) due to avoid penalty charge notices (PCNs) being issued to the registered keeper of the vehicle(s) associated to my account.

I confirm that I have read and fully understand the Dart Charge Terms and Conditions which can be obtained at www.gov.uk/dartcharge or by calling our Contact Centre on 0300 300 0120.

I confirm that I have read and accept the terms and conditions

Date*

Signature*

6. What To Do NextPlease send this form, along with your payment, to: Dart Charge, PO Box 842, Leeds, LS1 9QF

Please ensure that you pay the correct postage when sending your application form to us. We may make a deduction from your credit to cover insufficient postage paid.

If You Change Your MindWe hope you will enjoy the benefit of being a Dart Charge account holder, however, if you change your mind you have the right to cancel this Agreement within 14 days after we receive your application. If you wish to cancel, call us on 0300 300 0120. Alternatively, write to Dart Charge, PO Box 842, Leeds, LS1 9QF, or use the cancellation form which can be found at www.gov.uk/dart-charge and in your Welcome Pack.

About Dart ChargeHighways England are authorised to collect the road user charge on behalf of 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 emovis Operations Leeds 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).

All personal data will be processed in accordance with the GDPR and our privacy policy which can be found online: www.dartford-crossing-charge.service.gov.uk

DD/MM/YY

Instruction to your bank or building society to pay by Direct Debit Please fill in the whole form including official use box using a ball

point pen and send it to: Service user number

Dart Charge PO Box 842 LEEDS LS1 9QF

4 4 2 0 8 0

FOR emovis Operations Leeds LTD T/A Dart Charge OFFICIAL USE ONLY This is not part of the instruction to your bank or

building society.

Instruction to your bank or building society Please pay emovis Operations Leeds LTD T/A Dart Charge Direct Debits from the account detailed in this Instruction subject to the safeguards assured by the Direct Debit Guarantee. I understand that this Instruction may remain with emovis Operations Leeds LTD T/A Dart Charge and, if so, details will be passed electronically to my bank/building society.

Name(s) of account holder(s)

Bank/building society account number

Branch sort code

Name and full postal address of your bank or building society To: The Manager Bank/building society

Address

Postcode

Date

Reference

Banks and building societies may not accept Direct Debit Instructions for some types of account DDI1

This guarantee should be detached and retained by the payer.

The Direct Debit Guarantee

• This Guarantee is offered by all banks and building societies that accept instructions to pay Direct Debits• If there are any changes to the amount, date or frequency of your Direct Debit emovis Operations Leeds LTD T/A DartCharge notify you will 3 working days in advance of your account being debited or as otherwise agreed. If you requestemovis Operations LTD T/A Dart Charge to collect a payment, confirmation of the amount and date will be given to you atthe time of the request.• If an error is made in the payment of your Direct Debit, by emovis Operations Leeds LTD T/A Dart Charge or your bankor building society, you are entitled to a full and immediate refund of the amount paid from your bank or building society. Ifyou receive a refund you are not entitled to, you must pay it back when emovis Operations Leeds LTD T/A Dart Chargeasks you to• You can cancel a Direct Debit at any time by simply contacting your bank or building society. Written confirmation maybe required. Please also notify us.

Signature(s)