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Form C-Ef - Application For Certificate Of Public Convenience And Necessity For Operation Of Motor Vehicle Carrier Page 7

EXHIBIT FWA

Name:

Address:

Telephone No.

Fax No.

U.S.D.O.T. No.

ICC No.

Does Applicant have a Safety Rating from the U.S.D.O.T.?

Yes

Pending

(Submit when received)

(If “yes”, indicate rating and provide copy)

Satisfactory

Conditional

Unsatisfactory

Have any of Applicant’s drivers or vehicles been places “out of service” by Transport

Police safety officers in the past twelve (12) months?

Yes

Are there currently any outstanding judgement(s) against Applicant?

Yes

(If “yes”, indicate nature of judgement(s).

Is Applicant familiar with all statutes and regulations, including safety regulations,

governing for-hire motor carrier operations in South Carolina and does applicant agree to

operate in compliance with these statutes and regulations?

Yes

Is the Applicant aware of the Commission’s insurance requirements and the insurance

premium costs associated therewith?

Yes

(The attached Insurance Quote form must be completed, listing current insurance

premiums. At the discretion of the Commission, a copy of current insurance policies may

be required. Do not provide copy of insurance policies unless requested

(Applicant’s Signature)

Sworn to before me

This

day of

, 20

(Notary Public)

Commission Expires:

Form C-Ef - Application For Certificate Of Public Convenience And Necessity For Operation Of Motor Vehicle Carrier Page 7