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* INDICATES REQUIRED FIELD
CONTACT INFORMATION
*COMPANY NAME:
ADDRESS:
CITY:
STATE:
ZIP:
*CONTACT:
*PHONE:
FAX:
*EMAIL:
PICKUP INFORMATION
PICK UP DATE:
READY TIME: CLOSE TIME:
SHIPPER:
STREET ADDRESS:
*CITY:
*STATE:
*ZIP CODE:
PHONE #:
IS THERE A LOADING DOCK AT THE PICK UP LOCATION:
Yes No
 
DELIVERY INFORMATION
DELIVERY DATE:
DELIVERY TIME:
CONSIGNEE:
STREET ADDRESS:
*CITY:
*STATE:
*ZIP CODE:
PHONE #:
IS THERE A LOADING DOCK AT THE DELIVERY LOCATION:
Yes No
SERVICE LEVEL REQUESTED
NEXT DAY 2 DAY DEFERRED
*TOTAL PIECES:
DIMENSIONS (pcs @ L x W x H)
*WEIGHT:
*COMMODITY:
DECLARED VALUE:
SPECIAL INSTRUCTIONS: