General Info Sheet

Ma「k A McGriff, Owner/President

USDO丁# 291 2603

MC# 857159

EmaiI: ma「k@mcnationwide,COm

Mailing Address:

1607SW llTH COUR丁UNITI

「「 LAUDERDALE FL 33312

WWW.mCnationwide,COm

Phone: 954-263-3342

Fax: 954-368-5309

FEiN二46-391 5473

Bank: Capital One Spa「k

insurance: Surety bonds

Bond numbe「: 100316393

MC Nationwide is a加〃 service fogisf/cs company糾明y 〃censed, bonded, and insured

W鮎ch incIudes fmc勅〕ad seMce, L7T, /nte仰odal, MC Nationwide /s a member of 71A

(丁fanspohation /nte仰edfa万es Assocf弛oり, member of N17+ WationaI /ndus帥a1

77anspohafron Leagu?), member of仏NA /ntemodal Assoc融/on of No肩h Amehc争),

and we pa砧c小ate i両he EPA b (US Environmenfa/ Profec塙)n Ageney)

MC NAT音ONW看DE TRANSPOR丁AT漢0N LLC

1607SW 11TH COUR丁UN看TI

F丁LAUDERDALE 3331 2

0冊ce二954-263-3342

Fax: 954-368-5309

Customer Profiie

(informationaI Sheet)

Customer Name:

PhysicaI Address:

Ma臨g Address:

0冊ce/LocaI措

D&B ♯:

Accounts Payabie Contact: Name:

Federal iD#

丁elephone/Ext.　　Emaii

Type of Busjness: (Circie One) Corporation LLC Partnership SoIe Proprietorship Other

Owner(S) :

Year Business Established:　　Year Incorporated:_ Number of EmpIoyees:

Agreement ln consideration of MC Nationwide’s extension of credit

to Customer and other good and va!uabie consideration, Customer agrees that: (al Customer w旧ssue

Payment for MC’s invoices within thirty (30) days of MC’s invoice; (b) accounts which are th亜y-One (31)

days oId wi= be deIinquent and subject to review of credit p「iviiege and sha= bear interest of one and one

half percent (1 1/2 %) monthIy; (c) if co=ection is made by lawsuit or otherwise, Customer agrees to pay a=

Of MC’s coIlection costs incIuding reasonabIe attomey’s fees; (d) Customer waives and re=nquishes any

right to set-Off Customer’s cIaims (if any) against amounts due MC ; (e) copies of this Ag「eement, Whether

in the fom of facsimiIes, SCamed documents, Or OthenIVise, ShaIi be dup=cate originais and sha= be of the

Same legaI force and effect as originaI documents; and O this Agreement wi= be govemed by the Iaws of

the State of FIorida and Customer irrevocably agrees that any Iawsuit pe巾aining to this Agreement or any

Suit for coIIection of moneys owed by Customer to MC sha= oniy be fiIed in Magistrate Cou巾Or the

Superior CouれOf Broward County , FIorida, Customer submits itself/himse酬「erSeIf to the personai

jurisdiction of such Courts and irrevocabIy waives any right to assert that venue is not appropriate.

Read and Agreed this

Customer:

(Printed name of Custome子)

Signatu「e:

Authorized Agent:

(Printed name of person signing - TitIe)

F。叩W看9岬]ev. December 2014)

譜譜と諜諾語り

Request toJ Taxpaye事

Identi簡cation Numbel. and Ce鵬fication

Give Form to the

requeste「。 Do not

Send to廿Ie寡RS.

entity name, if different from above

、oYl小、心3 Check appropriato box for federal tax classification; Check only one of the followjng seven boxes:

□ IndjviduaVsoie pγOPrietor o「　□ c co'POration　口s corporation　□ partnership　　□ Trustfestate

昂智患葦豊an,.軸h。 ,。X 。Iassrf,。a,ton (C=C ∞,。。,a,i。n, S=S ∞,。。,ati。n, P=。。,tn。.Shi。) >

盤慧腔講話詣霊豊譜譜d’do not check LLC; check the appropriate box in t剛ne above for

□ other (See ins血Ctions) >

さ。諜誌罵鵜苫盛装instルctions on page 3):

Exempt payee c(rde Of any)

Exemption from FA「CA reporting

COde (if any)

5 Address (number, Street, and apt.

ゝ　∪∧

Requester’s name and add「ess topfronaD

ayer Identification Number叩N)

Enter your TiN in the app「OPriate box, The TIN provided must match the name given on line l to avoid

backup withholding. For individuals, this is generaily your sociai security number (SSN), However, for a

resident aIien, SOIe proprietor, Or disregarded en冊y, See the Pa「= instructions on page 3, For other

entities言t is your empIoyeI identification number (EiN). if you do not have a number, See How to get a

TW on page 3.

Note. 1fthe account is in more than one name, Seethe inst調ctions fo川ne 「 and the chart on page 4 for EmpIoyer identifi∞tion Ⅲmb鋤

Certification

Under penaities of perjury, i certjfy that:

1 ・ The number shown on this form is my correct taxpayer identification numbe「 (Or i am waiting for a number to be issued to me); and

2. l am not subject to backup withholding because:但) I am exempt from backup wjthhoIding, Or (b) i have not been no輔ed by the lntemaI Revenue

Service ORS) that l am subject to backup withhoIding as a resuit of a fa冊re to report a旧nterest o「 dividends, Or 〈d) the旧S has notified me tha= am

no 10nger Sub」eCt tO backup withhoIding; and

3・ l am a U.S. citizen or other U,S. person (defined below); and

4. The FATCA code(s) entered on this foI.m (if any) indicating that i am exempt from FA丁CA reporting is correct.

certificatioれinstnuctions" You must cross out item 2 above if you have been notifjed by the IRS that you are currentIy subject to backup withhoIding

because you have faiIed to report a旧nterest and dividends on your tax retum. For reaI estate transactions言tem 2 does not appIy, For mortgage

Genera= nstructions

Section references are to the lntemaI Revenue Code unIess otherwise noted.

Future deveiopments. 1nfomation about developments affectlng Fom W-9 (SuChas l印jsIation enacted after we 「elease it) is at wwwiIS.gOV/勅O.

Purpose of Form

An individuai or entity (Fom W-g reqUeSten Who is required to刷e an infomation

retum with the旧S must obtain yollr corJeCt taXPayeI idenl価cation number fllN)

Which may be youl SOCiai securfty numbe「 (SS時individua=axpayer identificaくion

number 〈mN), adoption taxpayer identification numberいTiN), Or emPIoyer

identificatIOn皿mber (EIN), tO 「ePOrt On an infomation retum the amount pajd to

yoll, Or Other amount reportable on an infomation retum. Exampies of informationretums include, but are not ijmited to, the foIiowing:

' Form 1 099-INT巾nterest eamed or paid)

. Form 1099-DIV 〈dMdends, including those from stocks or mし血ai fllnds)

' Fom l O99-MISC 〈various types of lnCOme, Prizes, aWards, Or grOSS PrOCeedS)

. Fom lO99-B (Stock or mutua=und saIes and certain other transactions by

bnoke「s)

' Fom l O99-S (PrOCeeds from reai estate transaction§)

● Fom 1 099-K (merchant cal’d and third party network transactions)

. Fom 1098 (home mortgage mtereS母1098モ(Student loan inte「esO, 1098-T

偉u摘on)

. Form lO99-C (canceIed debt)

. Fom l O99-A (acquisition or abandonment of secured property)

Use Form W-9 only ifyou are a U・S・ PerSOn (including a resident aIien), to

PrOvide your correct ¶N.

ffysuくねnOI Ielum Fo仰WL9 to勅e requeste( W肋a T時you migh! be su匂eci

to backup Mthho/ding. See WAat js back岬M〃書hho朋ng? on page 2.

By signing the fiiied-OUt form, yOU:

1. Certify that the TiN you are givnng is correct (Or yOU are Waiting for a number

to be issued),

2, Certify that YOU are nOt SUbject to backup withhoiding, Or

3. CIaim exemption from backup withholding if you are a U.S. exempt payee. 1f

applicable, yOu are aIso certifying that as a U.S. person, yOUr ailocabie share of

any partnership income from a U・S. trade or busineSS is not subject to the

WithhoidIng taX On foreign partners‘ share of effediveIy connected income, and

4. Certify that FATCA code〈$ ente「ed on個s fom Of any) indiCating that you are

exempt from the FATCA reporting, is colでeCt. See M】a書/s FA7℃A repor蹄g? on

Page 2 for furthe「 information.

Fo同W-9 (Rev. 12-20「4)

.剛急告uOS舌等己}s三〇意o轡S8S

〇〇台」o}u王国

㊦∪"S・ Department of Transportatjon

Fede「al Moto「 Ca巾e「 Safety Admjnistration

1200 New Jersey Ave., S.E.

Washington, DC 20590

SERVICE DATE

August O5, 2016

」iCENSE

MC"8571 59_B

U.S. DO丁No. 2912603

MC NATIONWIDE TRANSPORTATiON LLC

FT LAUDERDALE, FL

This Li∞nSe is eviden∞ Of the applicant’s authorty to engage jn operations言n inte「state o「 fo「eign

∞mmer∞, aS a broker, arranging fo「 transportation of打eight (excep宣househoId goods) by moto「

Vehicle.

This autho「ity wilI be effective as Iong as the b「oke「 maintains insu「ance cove「age fo「 the p「otection of

the public (49 CFR 387) and the designation of agents upon whom p「ocess may be served (49 CFR

366)・ The appiicant shaIi also 「ender reasonabIy ∞ntinuous and adequate servi∞ tO the pubiic. Fa=ure

to maintain ∞mPiiance w冊∞nStitute su飾cient grounds fo「 「evocation of this autho「ity.

雛了見二子Je冊ey L Secrist, Chief

lnfo「mation Technoiogy Ope「ations Division

BPO