Company name:	________________________________________________________
Mailing Address:	________________________________________________________
City, State, Zip:	________________________________________________________
Telephone:	__________________________	Fax:_________________________
Contact Person:	________________________________________________________
Email Address:	________________________________________________________
Please make copies of this form if you have more than one taxicab company.
Grand Total Cabs: _______ X $7.00 = $__________ plus base of $20 = $__________
I certify that the above information is true and accurate. Our dues payment in the amount of $_______________ is enclosed.  Dated: ________________
______________________________		_____________________________
Signed		Title