Membership Type Renewing MembershipNew Member
Company's Legal Name
DBA
Owner/Contact Name
Company Address
City
State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareWashington DCFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
Zip
Telephone
Cell
Email
Secondary Email
Secondary Email (Contact Name)
Web Address
Number of Years in Business
Membership in Other Industry Association? YesNo
Product(s) of Service(s) Offered
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? YesNo
Are you currently in compliance with all federal and state motor carrier operating licenses certificate or permit requirements? YesNo
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
