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 CMTA Application Online
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 CMTA Dues: (will be charged to Credit Card on the first of each month, Credit Card on file is required (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  
818-766-2682