DOMESTIC SHIPPING FORM 5524
* required fields
  Pickup Location:   Delivery Location:
Company Company
Address 1 Address 1
Address 2 Address 2
Zip
Zip
City City
State State
Contact Contact
Main No. Main No.
Fax No. Fax No.
Mobile No. Mobile No.
Email * Email *
 
   
(leave weight blank if you are not sure)
Make Model Serial Number Asset No. Lease No(s). Weight (lbs):
Insurance Amount: $  
Pickup location type:
Residential Commercial  
Delivery location type:
Residential Commercial  
Accessible to 53ft truck/trailer at pickup time? Yes No
Inside pickup? (select "no" if <100' from exit) Yes No
Stairs inside facility? If so how many (below) Yes No
If so how many inside:
COI required? (Certificate of Insurance): Yes No
Accessible to 53ft truck/trailer for delivery? Yes No
Inside delivery? (select "no" if <100' from exit) Yes No
Stairs inside facility? If so how many (below) Yes No
If so how many inside:
COI required? (Certificate of Insurance): Yes No
Pickup Loading Facility (choose one)
  Freight Dock
Street Level Accessible
Unleveled or Stairs
* If "YES" for stairs tell us how many outside:
Notes:
   
Delivery Loading Facility (choose one)
  Freight Dock
Street Level Accessible
Unleveled or Stairs
* If "YES" for stairs tell us how many outside:
Notes:
   
24hr Pickup pre-call info:
Contact with 24 hour notice at:
( E.g. Contact Contact Name with 24 hour notice at: Contact Phone number)

Open to Days
(E.g. Open 8am to 5pm M-F)
24hr Delivery pre-call info:
Contact with 24 hour notice at:
( E.g. Contact Contact Name with 24 hour notice at: Contact Phone number)

Open to Days
(E.g. Open 8am to 5pm M-F)
I agree to the terms & conditions of this shipment.
A copy of this form will be sent to the “Bill to” party.