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Truckers Dispatch Office Enrollment
Company Name: Fed. Tax ID/SS#:
Address:

MC Number:
City US Dot #:
State/Province: Insurance Co.:
Postal Code: Agent Name:
Country: Ins. Phone:
Phone Number: Ins. Fax:
Fax Number: Ins. Policy #:
Contact Name:    
Website:    
Email Address:    

I certify that I,  am the responsible party for   and all of the account(s) designated, and am entitled to provide the necessary authorization. I authorize Truckers Dispatch Office (TDO) to initiate electronic debit entries and, if necessary, credit entries and adjustment for any entries in error to the account(s) listed above. This authorization shall remain in effect until TDO receives written notice of direct debit termination from me in such time and manner as to afford reasonable opportunity for TDO and the Financial Institution(s) to act upon said request. Also, if I change or terminate my account(s) without notifying TDO in writing, I understand my services may be delayed. TDO PAYMENT

POLICY AND CREDIT CARD AUTHORIZATION: A one-time enrollment fee of $50.00, in addition to a monthly $349.00, which covers the first month of service by TDO, will be debited from your account upon sign-up for the service. There will be a recurring fee of $349.00 every thirty days after sign-up.

Truckers Dispatch Office  ▪ 4360 Packard Dr ▪ Hilliard, Ohio 43026