Named Credit Card or EFT Authorization Form

"*" indicates required fields

Member Number

Email Address

Member Name*

First Last

Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Billing Zip*

Authorized Representatives

Appointment 1 (Authorized Representative)

First Last

Appointment 1 Address

Street Address City State / Province / Region ZIP / Postal Code Country

Appointment 2 (Authorized Representative)

First Last

Appointment 2 Address

Street Address City State / Province / Region ZIP / Postal Code Country

Any transaction relating to OOIDA Drug & Alcohol Testing purchases will appear on my active credit card statement through the identifier “OOIDA”. I agree to pay all fees for services, state and federal fees combined. I am aware that I will receive a copy of the charge slip and that this slip will act as my record of each transaction. Failure to use services does not constitute a basis for refusing to pay any of the associated charges.

****Cardholder is required to provide verbal authorization payment and provide their full credit card number, expiration date, and the authorization code once the signed document is received. ****

By signing this form, you authorize your credit card or EFT to be charged by OOIDA for services purchased from Drug & Alcohol fees associated with this account.

Owner Operator Independent Drivers Association (OOIDA). requires a signed Named Authorization Form in order to allow anyone other than yourself to conduct business, or make an inquiry on your behalf related to your services. We are requiring this form in an effort to comply with the Federal Privacy Laws, as well as, protect your personal information and benefit plan(s).

The Named Authorization Form allows you to appoint an Individual(s) other than yourself to conduct business on your behalf. Please be sure to complete, sign, date, and submit if you choose to have us discuss your account with anyone other than yourself.

Please note this Authorization is not valid unless completed, signed and dated.

Remember to contact us at anytime you need to change the designation of your agent(s). In the event you choose to change your designated agent, we will require a new form for our files.

Get the Most From Your OOIDA Membership

Make sure you’re taking advantage of all OOIDA has to offer! From timely industry news and exclusive discounts to a full-line of insurance products and easy renewal options, everything you need is right at your fingertips:

Named Credit Card or EFT Authorization Form

Authorized Representatives

OOIDA Insurance Products

Business Services

Trucking Tools & Resources

Get the Most From Your OOIDA Membership