Membership Application

Name(Required)

First Last

Cell Phone(Required)

Email(Required)

Membership Type(Required)

Driver/Operator

Owner/Operator

Vendor

Hidden

Annual Membership Dues

Address(Required)

Street Address City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code

City Licensed to Operate(Required)

Boston

Cambridge

Other City (please specify)

Other City(Required)

Hackney #:(Required)

Medallion #:(Required)

Company Name:(Required)

By submitting this application, you represent and warrant the accuracy of the information, you and/or your company are in good standing with the Licensing Division of the Licensed City and the Massachusetts Secretary of State. As a member, you agree to abide by the Code of Ethics established for members of Way Forward Taxi Alliance, Inc.