GIBA TOLL PASS - PDF document

GIBA TOLL PASS APPLICATION Purcha
GIBA TOLL PASS APPLICATION Purchase Date ________________ Initial Expiration Date ________ Name ______________________________________ Address ______________________________________ City, State Zip _______________________________________ Phone ______________________ Cell Phone ______________________ Email ___________________________ Customer Signature _______________________ GIBA TOLL PASS TERMS AND CONDITIONS I am applying for a Gasparilla Island Bridge Authority toll pass. I certify that the information provided herein is accurate to the best of my knowledge. Once money has been put into my account I understand and accept that no credits or refunds will be issued under any circumstances. It is my responsibility to report lost or stolen cards and/or stolen or sold vehicles with the window sticker to the Gasparilla Island Bridge Authority as soon as possible. I understand that my account will be automatically cancelled and any money remaining in the account will be forfeited one year from the date of my last purchase. The Gasparilla Island Bridge Authority reserves the right to change, delete, limit, or modify at any time the terms of this agreement without advance notice. The Gasparilla Island Bridge Authority (GIBA) is not responsible for lost or stolen passes. The user of the pass agrees to abide by all GIBA bridge and causeway rules and regulations. Failure to comply may result in cancellation and loss of privileges. Fraudulent use of stolen or lost passes will result in criminal prosecution of the offender and loss of pass privileges. This is not a credit card. All cards and stickers remain the property of the Gasparilla Island Bridge Authority and if requested, I agree to return to the Gasparilla Island Bridge Authority office any and all stickers/cards. By signing above I verify I have read and understand these disclosures. For Administrative Use OPTION #1 OPTION #2 OPTION #3 Discount car pass 10 trip car pass Annual Car Pass 97.50 $ 60.00 $ 780.00 $ RFID Card/Sticker $5.00 each Total Due: ___________________ Account # _______________________ Card/Sticker #___________________________ ACCOUNT PAYMENT OPTIONS – You may open an account with a cash, check, or credit card. If you allow your account to run out your card will be denied. To replenish your account you may get an envelope from the tollbo

oth attendant (for check payments only),
oth attendant (for check payments only), visit our administration building or call in with your credit card information during business hours M-F 8:00am to 4:00pm. Automatic Renewal – For accounts that renew monthly Your account will automatically be replenished with your credit card by the amount you select. When your account balance reaches a low balance your credit card is charged for your renewal amount. Cards Accepted: AMEX, DISCOVER, MASTER CARD, VISA Card ____________________________________________ Expiration Date __________ Renewal Threshold _______________ Renewal Amount _____________ ____________________________________________ _____________ Cardholder Signature Date HOW LONG IS THE TOLL PASS GOOD FOR? The toll pass is active for one year from the date of your purchase. Any balance on your account remains accessible as long as your account is active. Your account will become inactive, one year from the date of your last purchase and all funds will be forfeited at that time. FEES for TOLL CARDS or STICKERS $5.00 - For each new or replacement toll card or sticker. GIBA VEHICLE TOLL RATES Discount toll pass -Maximum discount rate is $3.90 per trip (2 axle) 10 trip toll pass -$6.00 per trip for a car or pick up (2 axle) Commercial Trucks/Trailers -$5.50 for each axle GIBA ANNUAL PASS Vehicle Eligibility: Only cars and pick-up trucks are eligible for an annual pass. Dual wheel pick-up trucks, RV’s, commercial trucks, and trailers are not eligible for the annual pass. The annual pass allows the user to pay one fee, in advance, for 12 months of use. This fee allows the vehicle driver to make unlimited round trips for the one-year term. The cost of an annual pass is $780.00 plus the cost of the sticker. This option is one sticker, one car, one year, and requires the sticker to be affixed to the vehicle. NO EXCEPTIONS ANNUAL PASS TERMS AND CONDITIONS I understand that if I do not permanently attach the Annual Pass decal to ONE vehicle only, or if I circumvent this policy by any means, I will forfeit the privileges to use the GIBA Annual Pass program, my account will be cancelled, and any funds remaining will be forfeited to the Gasparilla Island Bridge Authority. Signature __________________________________________ Date _______________