Dangerous Goods Logistics Network

Membership PRE-QUALIFICATION Questionnaire

Please do NOT use all capital letters

Application for:

Full Membership - Exclusive

Full Membership - Regular

Associate Membership

Company Legal Name:

Other Names being used:

Contact Name:

Contact Job Title:

Address:

City:

State / Zip or Postcode:

Country:

Telephone:

Fax:

Email:

IM Address (if applicable):

Skype AIM MSNGoogleTalk

Website:

http://

Year Company established:

Branch Offices to be listed/enrolled (if in addition to Head Office listed above)

Average Annual Revenue during past 5 years:

US$

- of which % from DG:

Number of staff having DG Training:

(Part Timers, Consultants & Temps = 1/2)

- of which having > 10 years experience:

(Must be at least 1)

- of which having > 5-10 years experience:

Which Associations/Networks are you affiliated with?:

Are you licensed by any governmental authority?:

If YES, please provide details:

Is there a requirement to have your staff trained/certified in DG procedures by your trade association, govermental authorities, etc?

If YES, please provide details:

Do you have any lawsuits, insurance claims

or judgments outstanding against you?

If YES, please provide details:

Do you have any liability insurance specifically

covering your DG Activities?

Brief description of your company & its capabilities for

display in our "Members Only" section (Max 250 characters):

Finally, how did you hear about DGLN?

If another DGLN Member, please advise company name

to that we can give them the necessary credit: