818-766-2682

Membership Application

Advocating • Educating • Representing

CMTA Membership Application

Complete the application below. Required-field messages will appear under the related field.

Company Information

Fed Tax ID 
Application Date7/15/2026
Company Name 
Service Area (Counties) 
Bus Address 
Mailing Address 
Telephone 
Fax 
NPI 
Number of Vehicles in Operation 
Level of Service

CMTA Dues

CMTA Dues: (will be charged to Credit Card on the first of each month, Credit Card on file is required
(if paid in one installment in advance) - 10% discount applied

Principal Contact:

Name 
Title 
E-Mail 

Secondary Contact:

Name 
Title 
E-Mail 

Payment and Commitment

A $100.00 (one hundred dollars) application fee + $150.00 first month payment must accompany this form.

Please make check payable to CMTA

Mail payment to or pay online
2168 Moonbrook Cir
Roseville, CA 95747

By signing this application I agree for one year commitment (required for approval)

Authorized Representative Name 
Signature 
California Medical Transportation Association
818-766-2682 | marat@cmtasite.com