Company Name exactly as shown on ILCC License:
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ILCC License Number:
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Company Type:
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Individual owner
Partnership
Corporation/LLC
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Names of all owners, partners, or officers:
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Name of company’s on-site general manager:
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GM’s # years experience in moving industry:
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Other movers for which GM has worked and in what job duties?
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Company mailing address:
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Geographic Location (if different from mailing address):
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Business Reference: Co. Name & Contact Information:
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Why do you want to be a member of IMAWA?
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Telephone:
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FAX:
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Contact person’s e-mail:
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Contact person’s e-mail: needs to be a valid email address.
# Intrastate Trucks:
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What is your website address (URL):
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List other states in which you conduct transportation or storage for hire:
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Do you hold an interstate license (separate from any van line affiliation)?
Choose One
Yes
No
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What is your van line affiliation?
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List all other company names in which owner(s) or GM do now provide or ever have provided moving and/or storage service:
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