MAS Transportation Provider Network Application

MAS Transportation Provider Network Application

Owner Name*

Company Name (Legal Name)*

Company DBA Name (if applicable)

Tax ID Number*

Phone Number*

Phone

Street Address*

City & State*

Zip*

Email Address*

Primary County of Operation*

Select

Modalities Offered?*

Select all that apply

Taxi/Livery(0603,0605)

Ambulette Ambulatory (walks with assistance)(0602)

Ambulette Wheelchair(0602)

Ambulette Stretcher(0602)

Ambulance(0602)

Do you have DOT Operating Authority?*

Select

If Yes is selected please upload Authorization at bottom of form. If No selected please find DOT hyperlink at bottom of form

How many years have you been in business?*

<1 year

1-3 years

3-5 years

>5 years

What has been the company's focus?*

Ex. Public Hail Services, Private Services Only, Corporate Events, etc.

Average volume by week*

Operating Hours*

File Attachments

Please check the boxes below once files are attached. Include resumes for all Owners and Senior Managers. All files may be uploaded into the same File Upload field below (limit 10 file attachments).

Owners' Resumes*

Senior Managers' Resumes*

Licensure and Approval for Areas of Operation (if applicable)

DOT Operating Authority (0602 Only)

File Upload*

Drag and drop files here or

DOT hyperlink

Send me a copy of my responses

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