Agency Application

Agency Membership Application Form

General Info

Director *

Agency *

Address *

City *

Zip *

Website *

Work Phone *

Work Fax

Cell *

Email *

Notes

Representatives

Voting Representative

In the event the agency director is unavailable or chooses to assign voting privileges to another person of the member organization, the director may appoint a Voting Representative. Please assign a Voting Representative by providing the following information.

Appoint Voting Rep

Check here to appoint a Voting Representative

Training Representative

Please provide the name and contact information for the organization’s primary person responsible for training and staff development. This person will receive periodic correspondences regarding training opportunities available through ATA.

Appoint Training Rep

Check here to appoint a Training Representative

Voting Representatives

Name *

Work Phone *

Email *

Title *

Cell *

Training Representatives

Name *

Work Phone *

Email *

Title *

Cell *

Work Fax

Recaptcha

Agency Application

Agency Membership Application Form

Voting Representative

Training Representative

Advancing public transportation in Arkansas through education, technical assistance and training.