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Carrier Package

FIRST NAME

LAST NAME

EMAIL

COMPANY NAME

DBA (If Any)

ADDRESS

Address Line 1

Address Line 2

City

State

Zip Code

Country

EMERGENCY CONTACT NAME

WEBSITE (If Any)

DOT #

MOTOR CARRIER #

SSN/EIN

TWIC CARD

Equipment (All Flatbeds must have their own securement equipment to include tarps!!!)

Van/Reefer

Flatbed

Step Deck

Hot Shot

Box Truck

Other

Choose all that apply

Dolly

Air Ride

Pallet Jack

Straps/Binders

Tarps

Lift Gate

Dock High

PPE Gear

If other, please specify

Truck #

Trailer #

Trailer Length

Trailer Dimensions (Box Truck, VANs & Reefers ONLY L X W X H)

Lanes you like to Travel (will be discussed over the phone as well)

Cost per Mile ( Total Monthly Expenses/Miles per month + Average cost of 1 gallon of Fuel/Miles per Gallon your Truck averages = Cost per Mile) *Worksheet can be Provided

Factoring Company (to ensure we deal only with brokers that are approved by your company)

Factoring Company Agent Name (full name)

Factoring Company Email

Website (For Factoring)

Factoring Company Username

Insurance Company

Insurance Agent Name

Insurance Agent Email (for Certificate Requests)

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