Catalogue No. 45070923 Form No.

1236 (03/2013) ABN 76 236 371 088

E-Toll Tag Application
Frequent User
Infrequent User
Easy Toll Tag
Short Term Tag
Motorcycle Quarterly Pass
Terms and Conditions
Before you can access or use your Roads and Maritime Services (RMS) E-Toll Account, you must read and accept the Terms and
Conditions. These can be viewed online via www.myetoll.com.au or in the brochure E-Toll Tags and Pass which is available at any
NSW Motor Registry. The Terms and Conditions must be read carefully, as it explains the agreement between you and the Roads and
Maritime Services regarding your RMS E-Toll Account. Using your RMS E-Toll Account and Tag is an indication that you have read and
accept the Terms and Conditions.
Proof of identity
You are required to prove your identity before establishing an RMS E-Toll Account. A copy of the brochure "How to prove who you are"
is available at any NSW Motor Registry for your information.
Travel far and wide
Your RMS E-Toll Tag will make travelling easier on all roads in Australia. For more information, visit www.myetoll.com.au or call 13 18 65.
How it works
Open an RMS E-Toll Account and receive an electronic tag (with a tag bracket) to attach to the front of your windscreen (not applicable
to motorcycles). Every time you travel on a toll road a scanner will detect your electronic tag and automatically deduct the toll amount
from your RMS E-Toll Account. Your electronic tag will sound a short trill when detected.
Record keeping
With an RMS E-Toll Account, you will receive an itemised RMS E-Toll Account Statement via email or post. You can also request to
receive your RMS E-Toll Account Statement on a monthly or quarterly basis so keeping track of your toll usage is easy.
M5 Cashback Scheme
The NSW Government M5 Cashback Scheme allows NSW residents to claim back the value of tolls (excluding GST) paid while using
privately registered vehicles on the M5 motorway. Eligibility only extends to those vehicles that have private usage shown on their
registration, for example 'private general', 'charitable' or 'pensioner'. To register for M5 Cashback, ensure you tick the appropriate box
when completing section 2 of this application form. For more information, visit www.myetoll.com.au or call 1300 133 310.
Frequent and Infrequent Account
To open your RMS E-Toll Account, you are required to pay a $40 tag security deposit for each electronic tag, which is refundable when
the tag/s is/are returned undamaged. You are also required to pay an opening account balance to allow for immediate use. Your RMS E-
Toll Account balance will be topped-up automatically with an amount requested by you, and agreed by RMS when the account reaches
the minimum account balance.
Easy Toll Tag Account
To open your RMS E-Toll account, you are required to pay a one-off registration fee and a small monthly account fee. You have the
option of manually prepaying your tolls using cash at any NSW Motor Registry or you can have your account automatically topped-up
with an amount requested by you and agreed by RMS when the account reaches the minimum account balance.
Short Term Tag Account
To open your RMS E-Toll account, you are required to pay the weekly tag fee in advance for every week (or part of the week) that you
hold the tag. Each time your RMS E-Toll account reaches or exceeds a specified threshold an amount will be debited from your
nominated credit card.
Motorcycle Quarterly Pass
To open a Motorcycle Quarterly Pass account, you are required to pay for the pass on a quarterly pro-rata basis and the pass must
coincide with an RMS E-Toll Frequent, Infrequent, Easy Toll or Short Term Tag Account. The Motorcycle Quarterly Pass must be
renewed quarterly.
Transfer of vehicle
If you sell or dispose of your vehicle/s you must update your RMS E-Toll Account details immediately by calling 13 18 65 or visit your
local NSW Motor Registry.
Enquiries
If you have any enquires about applying for an RMS E-Toll Account, visit our website at www.myetoll.com.au, call 13 18 65 or visit your
local NSW Motor Registry to collect a copy of the "E-Toll Tags and Pass" brochure, which is a comprehensive guide in selecting the E-
Toll account that suits you.
RMS Office Use
Account ID number
Tag number
Number plate
Page 1 of 4
Select type of tag application
(the seven digit number
immediately after triple zero)
Customer Details
Title
Given names
Surname
ABN (if applicable)
Address Details
Residential address
Postcode
Mailing Address (if different from residential address)
Email Address
Phone (business hours) Phone (other hours)
Phone (mobile) Fax number
Account details
Complete your selected table below. (Only one option)
Infrequent User ($70 or less on tolls per tag, per month)
Tag security deposit
$40
Opening account balance
($40 minimum per tag)
$
Total opening amount =
$
Licence number (if applicable)
Page 2 of 4
1.
Business name (if applicable)
2.
3.
Postcode
Contact Details 4.
8.
+ (no. of tags) =
$
(no. of tags) =
$
Ongoing payment
Top-up Trigger
($20 minimum per tag)
Top-up amount
($20 minimum per tag,
$70 maximum per tag)
Infrequent users NB: RMS may increase your top-up
amount, rounded up to the nearest $10 and to a
maximum of $80 per tag, to cover your average monthly
cost of tolls (based on what you have spent over the
previous three months). When the calculated top-up
amount is more than $70 per tag, you will cease to be an
infrequent user and become a frequent user.
x
x
$
(no. of tags) =
$
x
$
(no. of tags) =
$
x
Frequent User (more than $70 on tolls per tag, per month)
Tag security deposit
$40
Opening account balance
($60 minimum per tag)
$
Total opening amount =
$
+ (no. of tags) =
$
(no. of tags) =
$
Ongoing payment
Top-up Trigger
($20 minimum per tag)
Top-up amount
($80 minimum per tag)
x
x
$
(no. of tags) =
$
x
$
(no. of tags) =
$
x
Short Term Tag (no deposit, weekly fee)
Weekly fee in advance
($5 minimum per tag)
Total opening amount = $
$ (no. of tags) = $ x
Account Statements (Please select one option below.)
Email statements (free of charge )
Emailed quarterly (Default)
Emailed monthly
Postal statements (a charge may apply)
Posted quarterly
Tax Invoice
(for business use)
Are you eligible for M5 Cashback?
Posted monthly
No
Yes
Are you over 18 years of age?
(You can no longer proceed with the application)
Do you have a good credit rating?
Do you accept the Terms & Conditions?
No
Yes
5.
(You can no longer proceed with the application) No
Yes
6.
(You can no longer proceed with the application) No
Yes
7.
continued page 3
Catalogue No. 45070923 Form No. 1236 (03/2013) ABN 76 236 371 088
Payment Option 1
(Does not apply to Easy Toll Tag Manual)
Nominated credit card details
MasterCard
Card number
/
Expiry Date
Payment Option 3
(Applies only to Easy Toll Tag Manual)
Motorcycle Quarterly Pass
You will need to have an existing RMS E-Toll tag Frequent
or Infrequent with only one motorcycle associated to the
account to utilise the motorcycle pass. Please note that no
other vehicle can be listed on this account. If you do not
have an existing RMS E-Toll account complete the
application form for a frequent or infrequent account .
I would like a motorcycle quarterly pass
The pass is available quarterly and payment is on a pro-
rata basis. You MUST renew your pass every quarter.
The motorcycle pass is available at any motor registry or
by calling Roads and Maritime Services Contact Centre on
13 18 65. The pass is NOT available online.
Payment Details 9.
Visa
AMEX Diners Club
Name/s on card
I am/We are the authorised nominated credit card holder/s entitled
to give the commitments in the Application. I/We have read and
agree to be bound by the Terms and Conditions for this RMS E-
Toll account and authorise RMS to charge the nominated credit
card above with all amounts, fees and charges as set out in or
payable under these Terms and Conditions. This authorisation is an
ongoing arrangement and will remain in force until I/We cancel it in
accordance with the Terms and Conditions.
Signature 1 on card
Signature 2 on card
Page 3 of 4
Cash Cheque
Credit Card Direct Debit
Payment Option 2 (Does not apply to Short Term Tags or
Easy Toll Tag Manual)
Nominated account details
Name of financial institution
Name/s on account with financial institution
BSB
I am/We are the authorised nominated account holder/s entitled to
give the commitments in this Application. I/We have read and agree
to be bound by the Terms and Conditions for this RMS E-Toll
account and authorise RMS to charge the nominated account
above with all fees, amounts and charges as set out in or payable
under these Terms and Conditions. This authorisation is an ongoing
arrangement and will remain in force until I/We cancel it in
accordance with the Terms and Conditions.
Signature of nominated account holder 1
Signature of nominated account holder 2
Account number with financial institution
Easy Toll Tag (no deposit, monthly fee)
Choose one options Manual or Auto
Manual Auto
Minimum Top-up
- $10.00
Opening Account
Balance - $30.00
In person
Online
Management Fee
$1.25*
Registration Fee
$1.50
$3.30
Minimum Top-up
Opening Account
Balance - $10.00
In person
Online
Management Fee
$1.25*
*
Registration Fee
$1.50
$3.30
Pensioner (eligible for discounted fees on the Easy Toll Tag
account only)
Pension card number Type
No
Yes
N/A
Each tag can only be used in one vehicle class. So, if you
want a tag in a car and in a truck, you will need two different
tags. Please specify below how many tags you would like
for each vehicle class and provide details of the vehicle in
which you will be using your tag/s.
Vehicle Description
1 - Car
2 - Truck
3 - Motorcycle
Vehicles 10.
4 - Bus (Metropolitan)
5 - Bus (Other)
Vehicle Class
Vehicle exceeding dimensions for Class 2.
Class 2 -
continued page 4
Discounted rates
for multiple tags
*
Discounted rates
for multiple tags
Vehicle under 2.8m high, with no more than two
axles. Or vehicle under 2.8m high, with no more
than two axles, towing trailer under 2m high with
only one axle.
Class 4 -
Easy Toll Tag Account - Manual users NB: If you have
chosen a manual account, you must maintain sufficient
funds for monthly account keeping fees and any trips
where you have used your Easy Toll Tag.
Catalogue No. 45070923 Form No. 1236 (03/2013) ABN 76 236 371 088
RMS office use:
Proof of identity record
Person
Stand-alone or primary proof
Document number
Secondary proof (if necessary)
Corporation
ACN verified from (specify document)
Verified by
Signature CSO number
You can authorise up to two people to have access to your
E-Toll account. By authorising the person/s named below,
you agree that they have given you permission to disclose
their personal information to RMS and to change their
details, including deleting them, as required. You also
acknowledge that the person/s nominated below can make
changes to your E-Toll account without your permission.
(At least one representative must be nominated)
Authorised representative 1
Create a phone password (12 characters maximum)
Please supply me:
I hereby certify that the details given above are complete
and correct. If I have included authorised representative/s I
have their approval to disclose their personal information. I
acknowledge I have received, read and agree to be bound
by the Terms and Conditions for a RMS E-Toll account as
determined by RMS at the time of this Application or as may
be varied by RMS in accordance with the Terms and
Conditions.
Signature
Date
Name
Position (if a business account)
Page 4 of 4
State
(in which the
vehicle is
registered)
Number
plate
Vehicle
Description
( 1 - 5 )
Vehicle
Class
( 2 or 4 )
Note: You can only nominate one number plate for a Short
Term Tag and Motorcycle Quarterly Pass.
Representative Details 11.
Title
Given names
Surname
Authorised representative 2 (optional)
Create a phone password (12 characters maximum)
Title
Given names
Surname
Tag Details 12.
tags for use in Class 2 vehicles and / or
tags for use in Class 4 vehicles.
Declaration 13.
/ /
day month year
Catalogue No. 45070923 Form No. 1236 (03/2013) ABN 76 236 371 088