PO Box 242337 • Montgomery, AL 36124 • Phone: (334) 834-3983 • Fax: (334) 262-6504
Application For Membership Motor Carrier: ___
Private: ___
Household Goods: ___
Allied Industry: ___
Your Dues Amount: $ __________________ (please fill in by using dues chart)
Firm Name:______________________________________________________________________________________ Address: (Box)________________________________(Street)____________________________________________
City, State & Zip: ________________________________________________________________________________
DOT Number: ______________________________________ Number of Trucks: ____________________________
Telephone: (______) ____________________ Fax (______) ____________________ 800/ ______________________
Website Address: ________________________________________________________________________________
Type of Business: ________________________________________________________________________________
Official Representative :________________________________ Title:______________________________________ Email address: __________________________________________________________________________________
Alternate Representative:________________________________ Title:______________________________________ Email address: __________________________________________________________________________________
Signed:________________________________ Date:________ Referred by:________________________________ CONTRIBUTIONS OR GIFTS TO THE ALABAMA TRUCKING ASSOCIATION, INC., ARE NOT DEDUCTIBLE AS CHARITABLE CONTRIBUTIONS. HOWEVER, A PORTION OF YOUR DUES ARE TAX DEDUCTIBLE AS ORDINARY AND NECESSARY BUSINESS EXPENSES.
CODE # _________________
Date_________________________
FOR OFFICIAL USE ONLY Mbr Type ____________________
Nxt Bill Date__________________
Check #______________________
Dues Cat _____________________
AL Sen______________________
Mbr Class____________________
Exp Date_____________________
CG Dist______________________
Dues Amt ____________________
Freq_________________________
AL Hse______________________
MAG ______ MC ______ GC ______ YR ______ LTR/PLQ ______ RSL ______ BC ______
A LABAMA T RUCKER • 1 ST Q UARTER 2018
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