MEMBERSHIP REGISTRATION FOR NORTHAMERICAN TRANSPORTATION ASSOCIATION

NTA Membership Registration

NORTHAMERICAN TRANSPORTATION ASSOCIATION
In applying for membership with NorthAmerican Transportation Association Inc. (NTA Inc) for the procurement of any of the association’s programs, I or We, are desirous of becoming a member of NTA and understand that the membership in NTA Inc. is limited to and made up entirely of separate transportation related companies consisting of at least one owner. NTA offers its members a free subscription to NTA’s High-Way Hi-Lites,” an electronic weekly newsletter & “10-4 Magazine”, a monthly electronic magazine.

We understand and agree that we must have on file a current credit card and/or electronic check payment form (ACH) at all times.

We understand that some benefits or services are for MEMBERS ONLY. To help new member companies establish a credit line, we understand that all accounts are reported to our in-house credit bureau on a monthly basis.

THIS FORM MUST BE SIGNED by an authorized representative from each company and returned with the applicable fees to NTA Inc. before any services or benefits can be started. Please keep copies of this form for your record keeping as proof of your association membership with NTA Inc.
Date

MonthDayYear
Date
Name of Company or Individual*
Mailing Address*
State*
Abbreviation
Zipcode*
Is your Physical Address the same as your Mailing Address?*

YesNo
Physical Address
City
State
Zipcode
US DOT Number*
MC Number
EIN or SSN*
Phone*
Fax
Email*
example@example.com
Website
Total number of employees you will enroll
Total number of Independent Contractors you will enroll*
Based on your latest MCS-150
By signing below, you acknowledge that you are legally signing this document.*

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NTA Membership Dues Rate Schedule for Motor Carriers & Independent Contractors. Membership includes a Free subscription to Hi-Way Hi-Lites (association electronic newsletter) and a Free subscription to 10-4 Magazine.

# of Drivers	Fee x Driver x 12 Months
1	$100
2-10	$4.50 Per Driver x 12 Months
11-20	$4.00 Per Driver x 12 Months
21-50	$3.50 Per Driver x 12 Months
51-100	$3.00 Per Driver x 12 Months
101-200	$2.50 Per Driver x 12 Months
201-500	$2.00 Per Driver x 12 Months
501 and Over	$1.50 Per Driver x 12 Months

Must be secured by either a credit card or an electronic check payment. Membership is Non-Refundable.

NTA Membership Dues (annual)
Calculation MemDues

Electronic Check or Credit Card Authorization
Please Select a Payment Type:*

Automatic ACH DeductionAutomatic Credit Card
Name on Check
Full Mailing Address
Type of Account

CheckingSavings
Bank Routing Number
Bank Account Number
Email Address for Electronic Receipt
example@example.com
Card Holder Name
Card Holder Address
Card Type

VisaMasterCardDiscover
Expiration Date

MonthDayYear
Date
First 8 Digits of Credit Card
For Security Purposes, Card Number is Split in Two
Last 8 Digits of Credit Card
For Security Purposes, Card Number is Split in Two
3 Digit Security Code
Found on the back of Card
E-mail Address for electronic receipt
example@example.com
By signing here, you acknowledge you are legally signing this document and authorize the NTA

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Total Charges for NTA Membership
Your billing invoice will be from NorthAmerican Transportation Association
Amount Authorized CC
FOR REFERENCE ON THE CREDIT CARD ACH FILE
Amount Authorized ACH
FOR REFERENCE ON THE CREDIT CARD ACH FILE
Thank you for your business and Welcome to the NTA!

Contact us with questions: 800-805-0040 or email info@ntassoc.com

You will be receiving a welcome email and will see billing charges on your payment account shortly. The NTA is happy to provide our Members with free Safety Consulting and business advice. Please don't hesitate to contact us if you have questions and need information. One of our NTA representatives will be happy to provide concierge service to your fleet needs.
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NTA Membership Registration

Electronic Check or Credit Card Authorization

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