Personal Information (Please print legibly)

Last Name ___________________First Name _________________Mid. Initial_____

Other Authorized Agent(s) ________________________________________________
Street Address__________________________________________________________
City ___________________________State ___________Zip Code _______________
Work Phone ( )________________ext.______Home Phone ( )________________
Drivers License (State)___________________ (Number)______________________
Email Address__________________________________________________________
Method of Payment (Choose credit card or EFT)
Credit Card
American Express
Discover Card
MasterCard
VISA
Exp. Date________________________
Account no. ______________________
Harris County has authorization to
charge my Credit Card account as
necessary to maintain the minimum
balance indicated below. This
authorization will remain in effect until
Harris County has received written
notice of its termination and has had
reasonable opportunity to act upon it.
Prepayment Amount (check one)
$40 Minimum, or
$_______________ (You may
set a higher minimum balance
to reduce the frequency with
which your card is charged.)
Signature_______________________
I, _______________________________ hereby make application to use the EZ Account, which will allow me to obtain passage on
the Harris County Toll Road system, via designated EZ TAG lanes. I acknowledge that I have read, understand, and will be bound by
the terms of this Agreement. I have indicated in my Application either the Credit Card payment option or the EFT payment option and
further, have provided the County with either my Credit Card number or my bank acccount number to effectuate the establishment of
my Prepaid Account. I hereby authorize Harris County to periodically charge my Credit Card and/or debit my bank account for the
amount(s) necessary to satisfy my obligations under this Agreement and the EZ Application provided.
(Signature required to avoid processing delays)
_____________________________________________________
Electronic Funds Transfer
Please submit your $80 prepaid
deposit, $15 (or applicable) EZ TAG
fee and a voided, blank check with this
application.
Harris County has authorization to
debit my checking account as necessary
at the bank indicated below. This
authorization will remain in effect until
Harris County has received written
notice of its termination and has had
reasonable opportunity to act upon it.
Bank Name______________________
Account Number_________________
Signature_______________________
Date ___________________________
Vehicle Information
Vehicle 1 License Plate
State_____________ Number ______________
Vehicle Description
Year___________ Color___________________
Make & Model __________________________
Vehicle 2 License Plate
State_____________ Number ______________
Vehicle Description
Year___________ Color___________________
Make & Model __________________________
Vehicle 3 License Plate
State_____________ Number ______________
Vehicle Description
Year___________ Color___________________
Make & Model __________________________
Receive monthly statements by: Email US Mail
For Offce Use Only
Number of EZ TAGs requested _______________
Account number assigned____________________
Clerk ID_________________________________
EZ TAG Sale Amount_______________________
Users Signature Date
(Provide for each EZ TAG requested)
Prepayment Amount (check one)
$80 Minimum, or
$_______________ (You may
set a higher minimum balance
to reduce the frequency with
which your card is charged.)
EZ TAG Number
EZ TAG Number
EZ TAG Number