MTA Annual Membership Application

Billing Information (if different from above)

Company Name

Contact Name

Address

City

State

Zip

County

Phone

Fax

Type of Carrier *

If other, please specify

For-Hire or Private Carrier *

$600 Home office in Mississippi - Four or less trucks

$600 Non-domiciled carriers, terminal located in Mississippi - Four or less trucks

$600 Non-domiciled carriers, no terminal located in Mississippi

$700 Allied Industry - Local, Regional, State or National

Addl Trucks x $20 per additional truck

For the first two carrier categories, enter trucks above the first four.

Payment Method *

Card Number

Expiration Date

Billing ZIP

CVC / Security Code

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