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Requester Affiliation

I am the (select all that apply): Shipper Consignee Third Party
Payment Terms*: Prepaid Collect


Requester Information

Contact: 
E-mail: 
Phone:  Ext: 


Shipper

   Company Name*:  
Name Plus:  
Street Address*:  
Country: 
City/State/Zip*:   
Contact*:  
Phone*:  Ext: 
Fax:  
E-mail:  


Shipment Specifics

Pickup Date*
Pro Number
Check Digit
TimeKeeper Shipment
Call to Arrange Pickup
Shipment Available
Business Hours  
Pickup Instructions
Linear Feet


Consignee

   Company Name:  
Name Plus:  
Street Address:  
Country: 
City/State/Zip*:   
Contact:  
Phone:  Ext: 
Fax:  
E-mail:  


Third Party

   Company Name:  
Name Plus:  
Street Address:  
Country: 
City/State/Zip:   
Contact:  
Phone:  Ext: 
Fax:  
E-mail:  


Commodities

Handling Units: 
# of type
Packages: 
# of type
 
Weight:
(lbs)
Class:
 
NMFC:
Item Sub
-
Cube:
(cuft)
Haz: 
 
(e.g. 2 pallets of 50 total cartons)
Description:

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Reference Numbers

 BOL Number: 
 PO Numbers:   Pcs   Wt   Dept  Customer Reference Numbers OR Return Authorization:
 More Reference Numbers


Additional Service Options

Pickup Options
Delivery Options
Other Options


Send Copy/Confirmation To

  Send copy of this Pickup Request to: Send confirmation notice when shipment is picked up to:
E-mail the Shipper
E-mail the Consignee
E-mail the Third Party

Also send to this e-mail address: