Named Credit Card or EFT Authorization Form

"*" indicates required fields

Member Number

Email Address

Member Name*

First Last

Name as it appears on card*

Address*

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

Credit Card Type*

Last 4 digits of credit card*

Please enter a number from 0000 to 9999.

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 CMCI 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 CMCI fees associated with this account.

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