Customer Information Verification Form - Business Account

To comply with Federal Bank Secrecy Act requirements, NC Quick Pass must review and monitor accounts that exceed certain funding thresholds. Customers who maintain a prepaid account balance greater than $2,000 or make a single replenishment of $10,000 or more are required to provide additional information for account review.

Complete this form to help us verify your account and maintain compliance with federal regulations. After review, the North Carolina Turnpike Authority will notify you if any updates or changes are needed.

Customer Information Verification Form (Business)

Applicant Information

Business Name(Required)

Mailing Address(Required)

Address 2

City(Required)

State(Required)

Zip Code(Required)

Type of Business Entity(Required)

U.S. State/Foreign Country of Organization(Required)

EIN(Required)

Business Entity (if not listed)

If your business entity is not listed, please add it.

Primary Contact

Title

First Name(Required)

Last Name(Required)

Primary Phone(Required)

Phone Type(Required)

Alternate Phone

Phone Type

Email Address(Required)

Confirm Email Address(Required)

Business Activity

Nature of Business(Required)

Number of Transponders(Required)

Transponders to be used for(Required)

Company Owned Vehicles

Privately Owned Vehicles

Both

Certification

Under penalty of perjury, I certify that the information provided herein is, to the best of my knowledge, accurate and complete.

Authorized Signature(Required)

Date(Required)

Printed Name(Required)

Title(Required)

CAPTCHA

Customer Information Verification Form – Business Account