Letter of Intent

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If you are interested in becoming a subcontracted transportation provider for MTM, please complete and submit the following form. Once we receive your information, you will be contacted by a member of our Network Management team based on our needs and available contracts.

Transportation Provider Name*

The Transportation Provider listed above offers this Letter of Intent as a show of good faith to proceed in a timely manner with subcontracting requirements and participation in the MTM NET program. This is not a contract nor is it an obligation to provide services and does not limit similar agreements with other NET brokers, provider clients, etc.

Business Name*

Contact Name*

Prefix

First Name

Last Name

Title of Contact*

Manager, Owner, Operator, etc.

Please enter full names for all owners (anyone who owns 5% or more of the company) and all officers.

Owner 1 Name*

First Name

Last Name

Owner 2 Name

First Name

Last Name

Owner 3 Name

First Name

Last Name

Owner 4 Name

First Name

Last Name

Owner 5 Name

First Name

Last Name

Owner 6 Name

First Name

Last Name

Phone Number*

Fax Number

Email Address*

Confirm Email Address *

Provider Company Website

Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Business Start Date*

How long has your transportation service been in operation?

Vehicle Inventory and Information

Description of Services Offered*

Ambulatory (sedan/black car/cab) Wheelchair/Ambulette Stretcher Ambulance - Basic Life Support Ambulance - Advanced Life Support Bus Bus - Deviated Fixed Route / Demand Response

Number of Ambulatory Vehicles*

Standard sedan, minivan or non-lift-equipped vehicles

Number of Wheelchair/Ambulette Vehicles*

Vehicles that provide manual or motorized wheelchair access and securement

Number of Stretcher Vehicles*

Manual, motorized or bariatric stretcher lift for riders in a prone position

Number of BLS/ALS Vehicles*

Basic Life Support / Advanced Life Support Vehicles

Number of Deviated Fixed Route Vehicles*

Do you operate a fixed route bus system or ADA Paratransit service?

Days and Hours of Operation*

Days and Hours of Operation
	Sunday	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday
Standard Business Hours (6:00 AM to 5:59 PM)	Days and Hours of Operation: Standard Business Hours (6:00 AM to 5:59 PM) (Sunday)	Standard Business Hours (6:00 AM to 5:59 PM) (Monday)	Standard Business Hours (6:00 AM to 5:59 PM) (Tuesday)	Standard Business Hours (6:00 AM to 5:59 PM) (Wednesday)	Standard Business Hours (6:00 AM to 5:59 PM) (Thursday)	Standard Business Hours (6:00 AM to 5:59 PM) (Friday)	Standard Business Hours (6:00 AM to 5:59 PM) (Saturday)
After Hours ( 6:00 PM to 5:59 AM)	After Hours ( 6:00 PM to 5:59 AM) (Sunday)	After Hours ( 6:00 PM to 5:59 AM) (Monday)	After Hours ( 6:00 PM to 5:59 AM) (Tuesday)	After Hours ( 6:00 PM to 5:59 AM) (Wednesday)	After Hours ( 6:00 PM to 5:59 AM) (Thursday)	After Hours ( 6:00 PM to 5:59 AM) (Friday)	After Hours ( 6:00 PM to 5:59 AM) (Saturday)

Specific hours of operation will be collected once contracted.

Primary State of Operation*

Base County*

In which county are you based?

Secondary State of Operation

Secondary State Base County

In which county are you based?

Secondary State Counties of Service or Service Area Description

Specific areas of service will be collected once contracted.

Languages spoken

English Spanish Russian Hmong Mandarin Arabic Vietnamese

Other:

Please check any languages spoken by management, dispatch, or drivers

Please share your most recent certification dates, if applicable.

Date Certified as a Historically Underutilized Business (HUB)

Date Certified as a Woman Owned Business Enterprise (WBE)

Date Certified as a Minority Owned Business Enterprise (MBE)

Date Certified as a Disadvantaged Business Enterprise (DBE)

Date Certified as a Disabled Veteran Enterprise

Date Certified as an Airport Concessions Disadvantaged Business Enterprise (ACDBE)

Current or Up-to-Date Insurance Coverage

General Liability (General Aggregate Amount)* $

Automobile Liability (Combined Single Limit)* $

Worker's Compensation* $