APPLICATION FOR MEMBERSHIP

Type of Membership

Regular         Associate Business         Sustaining

Name of Company:

Individual         Partnership         Corporation

Owner's Name: First -     Last-

Contact Person (if different from owner): First-     Last-
Title:

Street Address:
City: State: Zip:

Phone: Fax:

Email Address:

U.S. DOT #:

Federal I.D. #:

Ill C.C. #:

ICC #:

Type of Carrier: Common      Contract      Private      Leased

Commodities Hauled (check all that apply)

General Commodities
Grains
Seeds
Feeds
Livestock

Farm Supplies
Dairy Products
Road Building Materials
Building Materials
Steel

Logs/Lumber/Wood Products
Petroleum Products
Machinery/Heavy Equipment
Towing
Reefer

Fertilizer
Hazardous Material
Refuse/Scrap
Intermodal
Other

Services I am interested in being contacted on:

Regulatory & Compliance Assistance
Licensing & Overweight Permits
Workers Compensation Insurance

Drug & Alcohol Testing
Drug Free Workplace
Student Athlete Testing

Convention & Truck Show
Legislative Issues
Other


Membership Plans and Fees:

Card Type:
Card Number:
Expiration Date: Month - Year -

A $35 initiation fee will be added to your total.

I hereby apply for membership in the Mid-West Truckers Association, Inc. with membership dues of for the coming year. $5.00 of this amount is for a one year subscription to "Keep on Truckin' News".

In the event that the necessity would arise for Mid-West Truckers Association, Inc. to place any claim in litigation, applicant agrees that said clain would be under the jurisdiction of the Circuit Court of Sangamon County, State of Illinois, and further agree that there shall be added to the unpaid balance all court costs incurred, plus reasonable attorney fees.




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