Entity Name

dba (if different from above)

Contact Person

Title

Email address of contact person

City

State
AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareWashington DCFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennslyvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Zip

Telephone

Fax

Other Entity Locations (if applicable)

Is the entity, directly or indirectly, through stock ownership or otherwise, currently interested in ownership or control of any other organization? (If yes, list names.)

Is the entity, directly or indirectly, controlled by any other corporation, or does it operate pursuant to a managament or service agreement with any entity other than a customer/lessee? (If yes, list names.)

Year Started in Business

Approx. Number of Employees

Annual Revenue

State of Incorporation
AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareWashington DCFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennslyvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Number of Clients

List Officers, managers and affiliates authorized to bind the Applicant:

Every name the Organization has operated under and the correct mailing address of each of its offices for the past five (5) years (including any alternative names and names of predecessor and successor entities and names of any affiliates) along with the policy number and carrier for each workers, compensation insurance policy issued to the Organization under each and every such name in the past five (5) years:

Is the Organization a Professional Employer Organization (PEO) under its current name, or any name the firm may have at any time operated under? If yes, please list the name(s) of the company(s):

The name and address of each and every individual or entity who has had an interest in the Organization at the time of application; a list of each and every individual or entity who has an interest in the entity or its predecessors, successors, or affiliates in the preceding five (5) years; and the respective dates of ownership of each such individual or entity:

Have any principals of the applicant company served as an officer or shareholder in another contract labor provider or do they currently serve in such a capacity?

(If yes, give details):

Has the Organization named on the application ever conducted business under another name?

(If yes, give details):

What other Associations is the company affiliated with?

Does the entity issue IRS Form 1099 to any contracted drivers, warehousemen and others?

(If yes, give details and explanation):

Does the entity provide employees other than drivers and related distribution personnel? (provide % or head count)

Employee Staff Leasing

Temporary Help Service

Medical Personnel Staffing

Personnel Recruiting

Technical Staffing

Other (explain)

Note: I acknowledge that this application for membership to the Driver Employer Council of America is pending approval for membership by the Board of Directors of the Council. I further note that submitting this application does not assure that it will be accepted by the association either now or in the future. I recognize that any misrepresentation in completing this application may provide grounds for reconsideration and/or rejection of membership in the future.