Account Name: Phone: Ext:

Address:

City, ST ZIP ,

Contact: Costumer Ref # or P.O. #:

Email Address:

SHIP FROM: Phone: Ext:

Address:

City, ST ZIP ,

Contact:

Hours of Operation: Ready to ship date:

DELIVER TO: Phone: Ext:

Address:

City, ST ZIP ,

Contact: Add'l phone: Hours of Operation:

SPECIAL INSTRUCTIONS - Please Fill out Completely

Dock Origin Y N

Lift Gate at Origin Y N

In side pick up at origin Y N

Dock Destination Y N

Inside Delivery Y N

Lift Gate at Destination Y N

Curbside Delivery Y N

Uncrating Y N

Debris Removal Y N

Equipment Setup (if so describe below) Y N

Pad Wrap (number of pads required) Payment Type *Select Payment Info* Origin - COD Destination - COD Bill to Account

Flights No flights Origin Destination # of X-stop(s) If so, list details below.

Extra Insurance Y N Amount required ($5 per pound included at no charge)

List details of items to be shipped below. Include quantity, description, dimensions in inches (L/H/W), and weight per item in pounds.

List notes, instructions and shipment details below.