Complete the form below to submit your membership application. Company Information Company Name * Primary Contact * Address * City * State * AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Zip * County Phone * Fax Email * Number of Power Units Referred for Membership By Billing Information (if different from above) Company Name Contact Name Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Zip County Phone Fax Email Membership Type of Carrier * - SELECT -AutoAllied IndustryDumpRefrigeratedTankHousehold GoodsLTLPrivateOther (specify below) If other, please specify For-Hire or Private Carrier $600 Home office in Mississippi - Four or less trucks $600 Non-domiciled carriers, terminal located in Mississippi - Four or less trucks $600 Non-domiciled carriers, no terminal located in Mississippi AddlTrucks x $20 per additional truck Allied Industry * $700 Local, regional, state, or national Total Annual Membership Dues $ Workers' Compensation and OCC/ACC Program * YES, I am interested. NO, I am not interested. Policy Expiration Date Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year2023202420252026202720282029203020312032203320342035203620372038203920402041204220432044 Leave this field blank
