<p> 2050 Creve Coeur Mill Road Maryland Heights, MO 63043 Phone (314) 317-8818 Fax (314) 317-9408 Toll Free: 877-JMN-HAUL www.jmnhaul.com</p><p>1. Company ______</p><p>2. Street Address ______</p><p>3. City ______State ______Zip Code ______</p><p>4. Telephone Number ______</p><p>5. Fax Number ______</p><p>6. Email Address ______</p><p>7. Federal ID# (FEIN/EIN) or Social Security Number ______</p><p>8. Please give a concise description of company’s product(s), service(s), or type of business. ______</p><p>9. List Owners Name /Title Ethnic Origin* Ge nder US Citizen % of Ownership M F YES NO M F YES NO M F YES NO M F YES NO</p><p>*ETHNIC ORIGIN/MINORITY GROUP A citizen of the United States who is (1) Black, (2) Hispanic, or (3) Native American. (4) Asian Pacific whose origins are in Japan, China, the Philippines, Vietnam, Korea, Samoa, Guam, the U.S. Trust Territory and the Pacific Islands, the Northern Marinas Islands, Laos, Kampuchea (Cambodia), Taiwan, Burma, Thailand, Malaysia, Indonesia, Singapore, Brunei, Republic of the Marshall Islands, or the Federated States of Micronesia. Native American means American Indians, Eskimos, Aleuts, and Native Hawaiians. (5) Asian Indian Americans include United States citizens whose origins are from India, Pakistan, and Bangladesh.</p><p>10. Owner Operator (Please check one) YES NO</p><p>11. Date Business was established ______</p><p>12. Has your business ever applied for Minority, Women-Owned, or Veteran-Owned certification before? </p><p>YES NO</p><p>I (We) have completed and submitted the certification form as requested by JMN Logistics, and herby certify that the information contained herein are true, correct and accurate to the best of my (our) knowledge and belief.</p><p>Signature ______Date ______</p>