QUOTE NUMBER (OR AUTHORIZATION CODE):

CONTACT:

PHONE:

EMAIL ADDRESS:

CONSIGNEE:

ADDRESS:

CONTACT:

PHONE:

MILES:

EXTRA STOPS:

PRODUCT TO BE SHIPPED:

HOW PACKED:

APPROX. PC CT:

• LINE HAUL: $
• OTHER SERVICES:
• ESTIMATED TOTAL CHARGES: $

THE RATE QUOTE IS BASED UPON INFORMATION FURNISHED TO US. DEVIATION MAY RESULT IN TOTAL CHARGES BEING ADJUSTED.

SPECIAL HANDLING INSTRUCTIONS:

SUBMITTED BY:

THIS IS TO CERTIFY THAT YOU AUTHORIZE THE SHIPMENT AND BILLING IN ACCORDANCE WITH THE INFORMATION LISTED ABOVE.

PLEASE INVOICE ALL CHARGES TO THE FOLLOWING ADDRESS:

(IF P.O. BOX, INCLUDE STREET ADDRESS)

AUTHORIZATION CODE :

YOUR TITLE:

DATE: