Carrier Member Application This field is hidden when viewing the formCarrier Membership ApplicationArizona Trucking Association has represented and provided services for the trucking and distribution industry since 1937. To help us provide superior service to your company, please be sure to completely fill in all the blanks. If a question doesn’t apply to your company, simply write “N/A”. Thank you!COMPANY INFORMATIONMy company is joining as a (select one):(Required)Please Choose OneFor-hire Motor Carrier (hauls freight for other businesses)Private Carrier (hauls own company’s products)Type of business / Principal commodities hauled:(Required)Company Operates In:(Required)Please Choose OneIntrastate AZ OnlyInterstateCheck if any apply to your company: Household Goods Carrier Petroleum / Hazmat Carrier Specialized Carrier or Rigger Company Name:(Required)DOT#:(Required)Mailing Address(Required) Street Address City State / Province / Region ZIP / Postal Code Website(Required) Main Phone(Required)Owner / CEO Name(Required) First Last Title(Required)Email(Required) Office PhoneCell Phone*(Required)*By providing a cell phone number, you are opting in to receive text message updates from the Arizona Trucking Association (ATA). Phone numbers will never be shared, sold, or used for any purpose other than official ATA communications.Carrier Dues Schedule:(Required)Please select annual Arizona miles driven0 – 500,000 ($651.50)500,001 – 1,000,000 ($847.00 Annual Dues)1,000,001 – 2,000,000 ($1,237.75 Annual Dues)2,000,001 – 3,000,000 ($1,628.75 Annual Dues)3,000,001 – 4,000,000 ($2,019.50 Annual Dues)4,000,001 – 5,000,000 ($2,410.50 Annual Dues)5,000,001 – 6,000,000 ($3,127.00 Annual Dues)6,000,001 – 7,000,000 ($4,039.25 Annual Dues)7,000,001 – 8,000,000 ($4,690.75 Annual Dues)8,000,001 – 9,000,000 $5,472.50 Annual Dues)9,000,001 – 10,000,000 ($6,189.00 Annual Dues)10,000,001 – 11,000,000 ($7,036.00 Annual Dues)11,000,001 – 12,000,000 ($7,817.75 Annual Dues)12,000,001 – 13,000,000 ($8,600.00 Annual Dues)13,000,001 – 14,000,000 ($9,446.50 Annual Dues)14,000,001 – 15,000,000 ($10,163.00 Annual Dues)15,000,001 – 16,000,000 ($10,944.75 Annual Dues)16,000,001 – 17,000,000 ($11,726.50 Annual Dues)17,000,001 – 18,000,000 ($12,508.50 Annual Dues)18,000,001 – 19,000,000 ($13,029.50 Annual Dues)19,000,001 or more ($14,095.50 Annual Dues)Annual AZ Miles:(Required)Applications must be submitted with most recent IFTA report summary(Required)Max. file size: 32 MB.Registered number of Arizona power units & straight trucks over 10,000 lbs. GVWR:(Required)Total Years in Business:(Required)Please enter a number from 0 to 500.Years Conducting Business in Arizona:(Required)Please enter a number from 0 to 500.Please provide a short blurb describing your company. This will be used in our new member announcement.Please upload your company logo (jpg, png or pdf preferred)Max. file size: 32 MB.PUBLISHED CONTACTThis is the designated public point of contact. The name and phone number listed here will be included on contact lists shared with other Arizona Trucking Association (ATA) members upon request.Is the published contact the same person as the Owner/CEO list above?(Required) Yes No Published Contact Name First Last Published Contact TitlePublished Contact Email Published Contact PhonePublished Contact Cell Phone**By providing a cell phone number, you are opting in to receive text message updates from the Arizona Trucking Association (ATA). Phone numbers will never be shared, sold, or used for any purpose other than official ATA communications.Is Published Contact address the same as Company Address listed above?(Required) Yes No Published Contact Address Street Address City State / Province / Region ZIP / Postal Code BILLING CONTACT (If different from Owner/CEO)Billing Contact Name First Last Billing Contact TitleBilling Contact PhoneBilling Contact Email Billing Contact Cell Phone**By providing a cell phone number, you are opting in to receive text message updates from the Arizona Trucking Association (ATA). Phone numbers will never be shared, sold, or used for any purpose other than official ATA communications.HUMAN RESOURCES CONTACT (If different from Owner/CEO)Human Resources Name First Last Human Resources Contact TitleHuman Resources Contact PhoneHuman Resources Contact Email Human Resoures Contact Cell Phone**By providing a cell phone number, you are opting in to receive text message updates from the Arizona Trucking Association (ATA). Phone numbers will never be shared, sold, or used for any purpose other than official ATA communications.MARKETING CONTACTMarketing Name (If different from Owner/CEO) First Last Marketing Contact TitleMarketing Contact PhoneMarketing Contact Email Marketing Contact Cell Phone**By providing a cell phone number, you are opting in to receive text message updates from the Arizona Trucking Association (ATA). Phone numbers will never be shared, sold, or used for any purpose other than official ATA communications.PERSON RESPONSIBLE FOR VEHICLE LICENSING (If different from Owner/CEO)Vehicle Licensing Contact Name First Last Vehicle Licensing Contact TitleVehicle Licensing Contact PhoneVehicle Licensing Contact Email Vehicle Licensing Contact Cell Phone**By providing a cell phone number, you are opting in to receive text message updates from the Arizona Trucking Association (ATA). Phone numbers will never be shared, sold, or used for any purpose other than official ATA communications.SAFETY COMPLIANCE CONTACT (If different from Owner/CEO)Safety Contact Name First Last Safety Contact TitleSafety Contact PhoneSafety Contact Email Safety Contact Cell Phone**By providing a cell phone number, you are opting in to receive text message updates from the Arizona Trucking Association (ATA). Phone numbers will never be shared, sold, or used for any purpose other than official ATA communications.OTHER CONTACTSADDITIONAL EMPLOYEES FOR OUR DATABASE TO RECEIVE E-BULLETINS AND OTHER INDUSTRY INFORMATION.Other Contact 1 First Last Other Contact 1 Email Other Contact Cell Phone**By providing a cell phone number, you are opting in to receive text message updates from the Arizona Trucking Association (ATA). Phone numbers will never be shared, sold, or used for any purpose other than official ATA communications.Other Contact 2 First Last Other Contact 2 Email Other Contact2 Cell Phone**By providing a cell phone number, you are opting in to receive text message updates from the Arizona Trucking Association (ATA). Phone numbers will never be shared, sold, or used for any purpose other than official ATA communications.If you prefer to provide an excel spreadsheet for your company contacts, please upload belowMax. file size: 32 MB.ATA provides many opportunities to our members for marketing and networking.Please check any you would like to learn more about.ATA provides many opportunities to our allied members for marketing and networking. Please check any you would like to learn more about. Buyer’s Guide – products/services Drug & Alcohol Testing/Background Screening Owner/Operator Insurance PrePass Safety Alliance – Truck Bypass System Vehicle Registration Services – Safety Supplies Carrier ATA provides many opportunities to our allied members for marketing and networking. Please check any you would like to learn more about. Event Sponsorship: Truck Driving Championships/Carrier Conference/Other Events Safety & Maintenance Council Seminars/ Training Fleet Safety Awards Program Legislative Updates How did you hear about ATA? From another member Website Attended an ATA seminar or Event Total Preferred Payment Method(Required) Check Credit Card Credit Card American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Expiration Date Month Month010203040506070809101112 Year Year20252026202720282029203020312032203320342035203620372038203920402041204220432044 Security Code Cardholder Name Thank you for your application, dues payment and supporting documents. Once your application has been approved, you will receive a complete membership packet. For information in the meantime, contact us at 602-850-6000.
