| Address |
|
City |
|
| Province/State |
|
Postal/Zip Code |
|
|
If carrier payment is made to a third party: |
| Carrier Name |
|
Contact Name(s) |
|
| Address |
|
City |
|
| Province/State |
|
Postal/Zip Code |
|
| CARRIER
INFORMATION |
| Insurance policy
# |
|
Insurance Carrier
|
|
| Insurance Broker
Name |
|
phone # |
|
| USDOT number |
|
MC/MX number |
|
| CVOR number |
|
WSIB # (Workers
Compensation) |
|
| TYPES
OF SERVICE |
| LTL
FTL
HEAT
|
REFRIDGERATED
|
| HAZARDOUS MATERIAL
|
EXPEDITE: STRAIGHT
TRUCK/CUBE VAN
|
| LOCAL CARTAGE
|
FOOD PRODUCT
|
|
| BONDED : US
CDN
|
POST AUDIT
|
|
| SATELLITE TRACKING
|
PAGER
CELL PHONE
|
| TYPES
OF EQUIPMENT |
| # OF TRACTORS IN
YOUR FLEET |
|
|
| #
DRY VANS |
48'
|
53'
|
# REEFERS
|
# FLATBEDS
|
# DROP DECKS
|
# RACK & TARPS
|
CONTAINER
CHASSIS
|
STRAIGHT
TRUCKS
|
CARGO
VANS
|
CUBE
VANS
|
OTHER
|
|
|
|
| SERVICE |
| Please Indicate
Areas of Service |
|
| Please
give us 2 Freight Broker References and include
phone #s |
Reference # 1
|
|
Reference #2
|
|
| I
hereby state that the information I've submitted
is true. |
|
|
|
