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CMTA Application Online
Fed Tax ID
Application Date
11/28/2023
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 $ 150.00 / month
Annual $ 1,620.00
(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 + $150.00 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