United Equity Development Corporation
MEMBERSHIP APPLICATION


First: _______________________ MI: ___ Last: ____________________ Suffix (Sr., Jr., etc)____

Mailing Address: _________________________________________________________

City: ______________________ State: _____ Zip: ___________

Home: (____) ____ - _____ Cellular Phone: (____) ____ - _____ Pager : (____) ____ - _____

FAX : (____) ____ - ______ E-mail: _____________@__________ CDL# ____________State :___

Classification: ___ Independent Owner-Operator ___ W-2 Employee Driver ___ Student
___ Small Trucking Company Owner (#___ of Trucks) ___ Other
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Please take a moment to complete this short survey. It will help us to better serve the needs of the membership and to build political clout. Your personal information is considered private and confidential and will be aggregated with all members to describe the strength of our groups and its concerns.
Type of Driving: ___ Local ___ Container ___ Short Haul ___ Long Haul

Typical trailer: ___ Box ___ Flatbed ___ Refrigerator ___ Center Drop/Dump
___ Livestock___ Auto Carrier ___ Other (please describe____________)

Are you Haz Mat Licensed? ___ Yes ___ No
Are you registered to vote? ___ Yes ___ No If No, are you Eligible to vote? ___ Yes ___ No
If are you registered to vote is it via Absentee (Mail-in) Ballot? ___ Yes ___ No