Invest in FTA Membership Today! Rev 4-15 Choose your membership investment according to your needs:  Carrier Membership .............................. $595 annually + $20 per truck (maximum $5,995 annually) = $ ____________  Supplier Membership ............................ $595 annually + $100 per additional location in directory (Wholesaler, manufacturer, components, distributors, jobbers, dealers, agencies, truck stops) = $ ____________ TOTAL = $_____________ *An FTA staff member will call you to confirm receipt of your membership application and to answer any questions. MEMBER INFORMATION Company Name:____________________________________________________________________________________ Billing Address: _____________________________________________________________________________________ City/State/Zip: _____________________________________________________________________________________ Primary Representative: _____________________________________________________________________________ Job Title: __________________________________________________________________________________________ Mailing Address: ___________________________________________________________________________________ City/State/Zip: _____________________________________________________________________________________ Office Phone: ___________________________________ Mobile Phone: ____________________________________ Email: _________________________________________ Web: ____________________________________________ Number of trucks dispatched in Florida: ______________ US DOT Number: __________________________________ General business area:  Florida  Southeast  National  International  Other: ________________________ Each company membership comes with five Individual Memberships. Please give us the names for your 5 reps: Rep 1. (Person shown above) ______________________ 2.0 / T / S - 2. ______________________________________ Rep 2. _________________________________________ 2.0 / T / S - 3. ______________________________________ 2.0 / T / S - 1. ___________________________________ Note: Choose any combination of TMC (T), SMC (S) or 2.0 for your council reps. Indicate by circling by each name. Payment Information:  Check enclosed (payable to Florida Trucking Assoc.)  Visa  MasterCard  American Express Credit card number: _______________________________________________________ Security Code: _____________________________ Name as appears on card: __________________________________________________ Expiration: ________________________________ Statement Mailing address: _________________________________________________ Phone: ____________________________________ City/State/Zip: ____________________________________________________________ Email of person making payment (for receipt): _______________________________________________________________________________ Signature: ________________________________________________________________________________ Date: _______________________ Return Completed Application by Mail to: Florida Trucking Association, 350 E. College Ave., Tallahassee, FL 32301, By Email to: [email protected] OR By Fax to: (850) 222-9363