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Total Amount

On Behalf Of Organization

DOT# *

Organization Name must be your Legal Business Name and match the records in our system.
If you receive the error: Data does not match our records, please contact us at nvta@gonvta.org OR 518-694-4589 so that we may update your information.

Organization Name *

Street Address *

Address Line 2

City *

State/Province *

Country *

Postal Code *

Organization Email *

Organization Phone

Account

Please enter a Username to create an account. If you already have an account please login before completing this form.

Username *

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Punctuation is not allowed in a Username with the exception of periods, hyphens and underscores.

Password

Confirm Password

Provide a password for the new account in both fields.

Primary Contact (Owner)

First Name *

Last Name *

Email *

IP Address

98.80.143.34

Modified Date

October 7, 2024

Credit Card

Card Type

Card Number *

Security Code *

Expiration Date *

Billing Name and Address

Billing First Name *

Billing Middle Name

Billing Last Name *

Street Address *

City *

Country *

State/Province *

Postal Code *