Dart Charge account registration form

Register for a Dart Charge Account
Did you know you can register online at www.gov.uk/dart­charge
* Information that must be provided
1. About you
Title
Mr
Mrs
Ms
Miss
Other
First Name*
Middle Name
Last Name*
House number and street*
Town/ City*
County
Postcode*
Country*
Contact phone number*
Email Address
How would you like us to contact you?*
By Email
By Post
Once your account has been opened, we will send you a welcome pack containing all of the
necessary documentation
2. Vehicle details
Please use this section to tell us about the vehicles you would like to register for Dart Charge.
We will calculate your Dart Charge based on the information supplied below.
Vehicle 1
Vehicle Registration Mark
(Number plate)
Make (e.g Ford)
Model (e.g Focus)
Colour
Please tick if you would like to
receive a Dart Charge Tag for this
vehicle
Please select the vehicle class;
Class B: Car
Class C: 2 Axle Goods
Class D: Multi Axle Goods
Vehicle 2
Vehicle Registration Mark
(Number plate)
Make (e.g Ford)
Model (e.g Focus)
Colour
Please tick if you would like to
receive a Dart Charge Tag for this
vehicle
Please select the vehicle class;
Class B: Car
Class C: 2 Axle Goods
Class D: Multi Axle Goods
Vehicle 3
Vehicle Registration Mark
(Number plate)
Make (e.g Ford)
Model (e.g Focus)
Colour
Please tick if you would like to
receive a Dart Charge Tag for this
vehicle
Please select the vehicle class;
Class B: Car
Class C: 2 Axle Goods
Class D: Multi Axle Goods
Please confirm that you own the vehicle(s) above or have the permission of the
vehicle owner to register and receive information about their vehicle on their behalf
3. Payment details
To open a Dart Charge account a minimum payment of £10 is required. Dart Charge will deduct
this payment upon account creation.
You can also use this form to set up Auto­Pay. With Auto­Pay your account can top­up
automatically by recurring direct debit or card payment.
Please choose one* of the following:
Set your Dart Charge account up for Auto­Pay using Direct Debit.
Go to attached Direct Debit mandate form.
Set your Dart Charge account up for Auto­Pay using a payment card
Go to Section 3.1
Just pay £10 to create a Dart Charge account and manually top­up when required
Go to Section 3.2
3.1 Set your Dart Charge account up for Auto­Pay using a
payment card
When your CC auto­pay is active we will deduct the initial £10 payment automatically.
Once your account balance reaches the low balance threshold of £10 we will deduct a payment
from your card based on your chosen top up amount.
Top up amount £ *
Minimum top up amount is £10
Please tick one* of the following:
Visa
MasterCard
Amex
Maestro
Name on Card *
Card Number *
Expiry date *
Valid from
MM/YY
CVV
By signing the box below I authorise Dart Charge to charge my payment card with the amount
shown in the Total Payment Box Above
By signing the box below you are confirming you are the cardholder and that you authorise
Dart Charge as and when they become due for the purposes of Auto Pay from the payment
card specified above.
Signature *
Date *
DD/MM/YYYY
3.2 Pay £10 to create a Dart Charge account and manually top
,
up when required
Please tick one * of the following:
I am enclosing a cheque/ postal order for £10. Cheques or postal orders should be
made payable to Dart Charge
OR
I authorise you to debit my credit/ debit card for the above amount, by;
Visa
MasterCard
Amex
Maestro
Name on Card *
Card Number *
Expiry date *
Valid from
MM/YY
CVV*
4. Declaration
Please read the following declaration very carefully.
By signing this form, I certify that the details given on this form are to the best of my knowledge
true and correct. I understand that filing a false declaration knowingly and wilfully is a criminal
offence for which I may be prosecuted.
By signing this form I understand that I must allow 10 days processing time prior to my account
opening. Dart Charge cannot be held responsible for postal delays. If I do not allow adequate
processing time for the charge to be applied, Penalty Charge Notices may be issued to the
registered keeper of the vehicle for which they are liable.
By signing this form, I confirm that I have read and fully understand the terms and conditions
associated with having a Dart Charge account.
I confirm that I have read and that I understand the above declaration
Signature *
Date *
DD/MM/YYYY
A full copy of the Dart Charge Terms and Conditions can be found on gov.uk/dart­charge or you
request a copy by phone on 0300 3000 120.
5. Cancellation
You have the right to cancel this Agreement at any time within 14 days beginning on the day after
the contract is formed. If you wish to cancel, you simply need to tell us. You can tell us by phone
on 0300 3000 120, by writing to Dart Charge, PO Box 842, Leeds, LS1 9QF or by using the
cancellation form which you can find at www.gov.uk/dart­charge or in your Welcome Pack.
You may terminate this Agreement on 30 days' notice to us either in writing, by telephone or
online via the Website.
I request that my account is opened and activated prior to the expiry of the 14 day
cancellation period to which I am entitled. I acknowledge that by activating the
account early, I am under an obligation to pay for any charges and other account
services provided up until cancellation should I subsequently exercise my right to
cancel.
Finally
Please send this form with your Dart Charge payment to:
Dart Charge, PO Box 842, Leeds, LS1 9QF
Ensure that you pay the correct postage when sending your application form to us. You may be
charged if insufficient postage is paid. We may do this by deducting the amount of postage from
your account credit
About Dart Charge
We are 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 Sanef Operations 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).