FDOT Premium Wallet Certificate Card Order Form

Name

This field is for validation purposes and should be left unchanged.

Name(Required)

First Last

Email(Required)

Phone(Required)

Full Driver's License Number(Required)

Current Certificate Number

Shipping Address(Required)

Street Address Address Line 2 City State ZIP Code

PAYMENT IS REQUIRED PRIOR TO MAILING OF WALLET CARD

YOU WILL RECEIVE AN EMAIL INVOICE TO MAKE PAYMENT FOR WALLET CARD