MyACCESSRide.com

EPURSE DEPOSIT FORM

|

REVISED 12/17

ePurse Deposit Form

PLEASE PRINT:

ACCESS ID #_____________________

Name ___________________________________Phone (

)___________________________

Address _____________________________________________________Apt. # _____________

City _________________ State _____Zip Code _______Email____________________________

ADDRESS CORRECTION

:

Please check here if this is a new address.

**************************************************************************************************************************

You may deposit any amount that you wish into your electronic purse using a check, money order

or charge.

PLEASE DO NOT SEND CASH.

Make your check or money order payable to

ACCESS and mail to the address listed at the bottom of this form.

NOTE: A 50¢ postage and handling fee will be deducted from your deposit.

Deposit Amount $__________________

For credit card purchases, please complete the following section.

PLEASE NOTE

:

ACCESS

WILL NOT

process your order without a

valid credit card

,

expiration

date

and

authorized signature

.

There will be a $15.00 fee for each charge denied after

purchase:

Charge to my:



MasterCard



Visa



Discover



American Express

Credit Cardholder Information

:

_____________________________________

(______)_____________________________________

First Name

Initial

Last Name

Home Telephone Number

____________________________________

Credit Card #______________________________

Address

Apt.

Expiration Date____________________________

______________________________________

____________________________________________

City

State

Zip Code

Signature

Make Check/Money Order payable to

ACCESS

and mail to

650 Smithfield Street, Suite 440

Pittsburgh, PA

15222

.

For more information, call ACCESS at (412) 562-5353 or TTY 711.