APPLICATION EURO EMISSION CLASSES (Form 1A) - Dars

APPLICATION EURO EMISSION CLASSES (Form 1A)APPLICATION FOR ADJUSTMENT AND/OR ISSUE OF ELECTRONIC MEDIA OF DARS d.d.* FOR TOLL PAYMENT WITH RESPECT TO EURO**EMISSION CLASSES FOR MOTOR VEHICLES OF WHICH THE MAXIMUM PERMISSIBLE WEIGHT EXCEEDS 3.5TInformation on the person liable for toll:(All fields must be completed)Name of company/name and surname of the user:Address:Post code and post:Country:Liable for VAT: - YES - NO Tax number:Contact person:Telephone number:Electronic address:Fax:WE WISH TO HAVE OUR ELECTRONIC MEDIA ADJUSTEDWe are in possession of electronic media of DARS d.d. for non-cash toll payment in the Republic of Slovenia which are listed in the attachment P-1 by type ofmedium, serial numbers (for ABC and DC) and identification numbers (for ABC). For each vehicle for which toll will be paid in future with respect to the EUROemission class, the registration number and EURO emission class has been specified.WE WISH TO ORDER NEW ELECTRONIC MEDIAAs specified in the attachment P-1, we wish to order new electronic media (ABC and/or DC) for our vehicles as listed in the attachment, including theregistration numbers and EURO emission classes.After vehicle adjustment for the toll payment with regard to the EURO emission class, we issue a (used) ABC system electronic tag free of charge. Credit in theminimum amount of EUR 20 has to be loaded on the DARS Card (DC).Mark the post-payment electronic media in the fifth column of the attachment P-1 by adding letter P to the designation of the electronic medium (ABC-P, DC-P). DC cards used as a post-payment medium, for which a prior Deferred Toll Payment Contract has to be concluded with DARS d.d. or which will beconnected with a valid payment card upon collection, are distributed free of charge and without preloaded credit.DELIVERY POINTWe will collect the ordered electronic media from the attachment P-1:( - mark appropriately)in person at DARS d.d., Road Toll User Centre, Ljubljana, Grič 54 (CUC, motorway maintenance base Ljubljana, exit Lj-Brdo)via express mail _______________________________________ (enter the express mail provider; postage to be paid by the addressee)at the toll station _____________________ in the direction of ______________________.(please state at which toll station and in which direction you wish to collect the media)We will pay the purchase price and prepaid credit for the electronic media from the attachment P-1:( - mark appropriately)by pro forma invoice (the original delivery note constitutes proof)by cash or by payment card (only upon personal collection in CUC)under a Deferred Toll Payment Contract; Contract no.____________________MANDATORY ATTACHMENTS TO THE APPLICATION (Original documents will be returned to the applicant)( - mark the attachments to the application)List of vehicles and electronic media (attachment P-1)Photocopy of certificate of registration (for vehicles registered abroad),Original proof of compliance (of production) or CEMT permits (for vehicles registered abroad)Original proof of compliance (of production) or roadworthiness test certificates for the vehicles according to CEMT resolution (for vehicles registeredabroad)We declare that all the information in the application and attachments is accurate and that we are acquainted with the General Conditions for the Use ofElectronic Media of DARS d.d. for Toll Payment and with the Instructions for the Use of the Electronic Media of DARS d.d. In the case of false informationfor adjustment or issue of electronic media for toll payment in respect of EURO emission classes or the use of these media contrary to General Conditions,we undertake to pay the underpaid toll for all journeys conducted on toll roads in the Republic of Slovenia on the basis of an invoice issued by DARS d.d..DARS d.d. undertakes to enable toll payment by electronic media for the vehicles which are the subject of this application within 30 days of receipt of a complete application withthe attachments. Use of the electronic medium for toll payment with respect to the EURO emission class will be enabled upon receipt of electronic notification by DARS d.d.stating that the information on the vehicle has been entered into the electronic toll collection system. The information will be automatically recorded on the electronic mediumupon the first passage of the vehicle through the so-called combined lane of the toll station, marked thus .Personal data is protected according to provisions of the law which regulates personal data protection.In ______________________ on ____________ ____________________________________Stamp and signature of the applicant:* ABC electronic tag (ABC) and DARS Card/DARS Transporter Card (DC)** emission classes: E3 includes vehicles of EURO III emission class; E4 includes vehicles of EURO IV, EURO V, EURO EEV and EURO VI emission classesIn the case of any questions or doubts concerning toll payment on the toll roads of the operator, please contact the Road Toll User Centre (CUC) by phone:080 15 03 or +386 (01) 518 8 350, or by e-mail: cuc@dars.si, www.dars.si