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 CMTA Associate Application
Fed Tax ID   Application Date 6/23/2024 Company Name   Bus Address   Mailing Address   Telephone   Fax   NPI   Type of Product you offer     Principal Contact: Name   Title   E-Mail   Secondary Contact: Name   Title   E-Mail   A $200.00 (two hundred dollars) application fee + $400.00 annual payment must accompany this application. Please make check payable to CMTA Mail payment to 6000 Mystic Way Roseville, CA 95747 By signing this application I agree for one year commitment (required for approval) Authorized Representative Name   Signature  
818-766-2682