CMTA Application

Fed Tax ID Application Date 10/19/2020 Company Name Bus Address Mailing Address Telephone Fax NPI Service Area (Counties) Number of Vehicles in Operation Level of Service Ambulatory Ambulatory Door to Door Wheelchair Gurney CMTA Dues: (will be charged to Credit Card on the first of each month, Credit Card on file is required Monthly $ 200.00 / month Annual $ 2,160.00 (if paid in one installment in advance) - 10% discount applied Principal Contact: Name Title E-Mail Secondary Contact: Name Title E-Mail A $100.00 (one hundred dollars) application fee + $200.00 first month payment must accompany this form. Please make check payable to CMTA Mail payment to 11647 Morrison Street North Hollywood, CA 91601 By signing this application I agree for one year commitment (required for approval) Authorized Representative Name Signature