Membership Application

Fill out the form below to complete the MLA Membership Application!

Membership Type

Company's Legal Name

DBA

Owner/Contact Name

Company Address

City

State

Zip

Telephone

Cell

Email

Secondary Email

Secondary Email (Contact Name)

Web Address

Number of Years in Business

Membership in Other Industry Association?

Vendor's Membership

Product(s) of Service(s) Offered

Operator's Membership

Total Number of Vehicles in Your Fleet

Check the appropriate box to indicate all vehicle types in your fleet
SedanSUVStretchStretch-SUVShuttleBusHybridSpecialtyWheelchair Accessible

Primary City You Service

Secondary City You Service

Insurance Provider

Insurance Telephone

Policy Number

PSC #

DOT #

MC #

If you are operating one or more commercial motor vehicles in interstate and/or intrastate commerce are you currently in compliance with all federal and state requirements prescribing mandatory minimum levels of public liability insurance coverage?

Are you currently in compliance with all federal and state motor carrier operating licenses certificate or permit requirements?

OATH: I affirm That all the information contained within is true and correct to the best of my knowledge

Please Confirm This Oath By Signing Below

Electronic Signature

Date