NORTHAMERICAN TRANSPORTATION ASSOCIATION INC

This Credit Card Authorization MUST be on file with NorthAmerican Transportation Association before any goods or services will be rendered regardless of your preferred method of payment. An itemized invoice will be prepared for those companies who qualify for a credit account otherwise services must be paid for in advance or at the time services are rendered. For your convenience, in addition to cash or company check (no personal checks accepted with a guarantee card), we accept the various cards listed below.

Use this form to authorize NorthAmerican Transportation Association Inc to accept and bill your credit card, please complete all fields, SIGN and date, and fax to 800-810-6998 or return via mail to NTA. Please PRINT clearly. INCOMPLETE FORMS CANNOT BE PROCESSED. ALL INFORMATION will be kept on file and is strictly confidential.

Cardholder Name:____________________________________Signature_______________________________

Cardholder Address: _______________________________________________________

City/St/Zipcode: __________________________________________________________

Company Name: _________________________________________________________

NTA Account #: ________________                 NTA Invoice Number ______________________

Credit Card Number: _____________________________________________________

Card Verification Value Code# ______________   This number is printed on your MasterCard & Visa cards in the signature area of the back of the card. (It is the last 3 digits AFTER the credit card number in the signature area of the card.) On American Express, it is the 4 digit number on the front of your card either on the right or left side of the credit card.

Expiration Date: Month/year :_____________________________

Est Amt subject to additional taxes, S / H etc:_____________________

□ VISA     □  MasterCard     □  American Express

□ Monthly     □  Quarterly     □  Yearly

Deduction Date: _________

□ One Time Use: I hereby authorize NorthAmerican Transportation Association Inc to charge the indicated credit card the amount indicated above. This is a one-time charge authorization. I am NOT authorizing NTA Inc to setup my account within a recurring billing system – rather, I prefer to pay by check or money order on all future invoices. I understand that if I wish NTA Inc to charge any balances to my credit card in the future, I will need to submit another authorization form at that time or choose the selection below.

□ Recurring Billing: I hereby authorize NTA Inc to charge the indicated credit card the amount indicated above on a recurring basis as shown above, as currently applies for what I requested at the time of account sign up. I agree that this is a periodic charge that will be made according to the billing cycle, and that to terminate the recurring billing process I must cancel in writing 30 days in advance, or arrange for an alternative method of payment.

Authorization: I hereby authorize NTA Inc to charge the indicated credit card. I agree that this is either a one time or periodic charge that will be made as indicated above. To terminate the recurring billing process, if selected, I must cancel in writing, and then the account will be manually invoiced and payment must be made by check or money order. I understand that all account cancellations must be made in writing. I will not dispute NTA’s recurring billing with my credit card issuer so long as the amount in question was for the service rendered prior to my canceling my account in the manner required. I agree that if I have any problems or questions regarding my NTA account, I will contact NTA Inc for assistance, using the contact information located on their web site at www.ntassoc.com. I agree that I will not dispute any charges from NTA Inc unless I have already attempted to rectify the situation with NTA Inc and those attempts have failed. I authorize NTA Inc and their sponsoring agency to run an address verification search. This verification process is a security measure to protect me, the client, from illegal fraud against my credit card. I guarantee and warrant that I am the legal cardholder for this credit card, and that I am legally authorized to enter into this one time or recurring billing agreement with NTA Inc.