RATE REQUEST FORM

Company

Name: Title:

Company:

Tel. No. - - Ext:

E-mail:

Business Type: List Other Business Type Here if Required:

Freight Availability

Date: Month Day: Year: Time:

Delivery Date Requested: Month Day: Year:

Frequency:

Origin

Company Name: City: State/Prov: Zip/Postal Code:

Destination:

1. Company Name: City: State/Prov: Zip/Postal Code:

2. Company Name: City: State/Prov: Zip/Postal Code:

3. Company Name: City: State/Prov: Zip/Postal Code:

Commodity Description:

Total Gross Weight FTL: LTL:

Palletized Freight: If Palletized: # of pallets:

If Not Palletized: Floor Loaded: Trailer Length: ft

Dimensions: L x W x H

Hazardous Material: UN # Class Declared Value: $

Loading Time: Unloading Time:

Equipment Required: List Other Equipment Required Here:

Currency Used for Rate: Temperature: Reefer:

Comments: