Application

General Information

Name of Firm

DBA (if applicable)

Address 1

Address 2

City

State

Zip

Website

Birthday

Phone

Fax

Application Submitted By

Title

DOT Number (if applicable)

How did you hear about us?

Main Point of Contact Information

The main POC will receive annual membership invoice, unless otherwise requested. The main POC will also receive IMTA mailings, weekly newsletter the Truck Talk Weekly (TTW), our Crossroads Quarterly and Membership Directory & Resource Guide. The main POC will also be listed in the Membership Directory, under the people listing section.

Copy from Organization-Information

First Name

Last Name

Address 1

Address 2

City

State

Zip

Title

Phone

Birthday

If you would like to add other contacts from your company to our publication mailing list for (TRUCK TALK WEEKLY, CROSSROADS QUARTERLY AND MEMBERSHIP DIRECTORY & RESOURCE GUIDE), please list them below.

Additional Contacts

Add/Remove Contacts

Contact 1

First Name

Last Name

Title

Email Address

Contact 2

First Name

Last Name

Title

Email Address

Contact 3

First Name

Last Name

Title

Email Address

Contact 4

First Name

Last Name

Title

Email Address

Contact 5

First Name

Last Name

Title

Email Address

Contact 6

First Name

Last Name

Title

Email Address

Contact 7

First Name

Last Name

Title

Email Address

Contact 8

First Name

Last Name

Title

Email Address

Contact 9

First Name

Last Name

Title

Email Address

Contact 10

First Name

Last Name

Title

Email Address

Billing Address (if different)

Address 1

Address 2

City

State

Zip

Membership Investment

Membership Type

Type of Service Provided

How many employees do you have?

Total

Credit Card Information

Copy from Organization Information

Credit Card Type MastercardVisa

Credit Card Number

Name on Card
Security Code
Valid Through
Address
City
State
Zip
Phone
Credit Card Email Address

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Contact 1

Contact 2

Contact 3

Contact 4

Contact 5

Contact 6

Contact 7

Contact 8

Contact 9

Contact 10