Maine Professional Drivers Association
Application for MPDA Membership
Please mail this application to:
Maine Professional Drivers Association,
Web Site: www.mpda.org E-mail: membership@mpda.org
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Applicant's name:
______________________________________ Tel #:
_____________________________________
Company Name (if supporting member):
________________________________________Tel #:__________________
Mailing Address:
_________________________________________________________________
City, State, Zip:
________________________________________________________________
Birth date: _____/_____/______
Spouse's Name: ____________________
Email address: ____________________@______________ญญญญญ_________
Drivers License
#:____________________ State:
__________
Employed by or Leased to:
________________________________________________________
Address:
_________________________________________________________________________
Are you a company [__] or individual ? [__]
If Company Application:
Contact person:
____________________________________________________
Your position with company:
______________________________________________________
Years in
the trucking industry? - Present Company: ____ Trucking Industry: ____
Years since
last accident? ____ Years since last traffic violation?
_____
Person who gave you this application
or location where you picked it up at:
__________________________________________________________________________________
Type Membership applying for (check
one)
Driver: [___] Associate (non-drivers): [___] Supporting (companies or organization):
[___]
$25 Individual [__] - $65
Supporting [__] (please
make checks out to MPDA) Are your dues included? Yes [__] / No [__]
I acknowledge that, to the best of
my knowledge, all the above information is true.
Signature: ___________________________________________________ Date: ____/____/________
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For Association use only:
Application Rec'd ____/____/____ Member Officer Approval ______________
Dues Rec'd ____/____/____ Board Approval
______________________________
By-laws Sent Yes ____ / No ____ /
Membership # _____________________
MPDA
2008-2/24/08