Instructions: Please complete this form giving us all the information that pertains to you and your company. The better informed we are, the better we will be able to assist you. This form should be updated at any time by notifying us. This information is for ouruse only and will not be released to any third party without your express written permission.

Number and Type of Equipment: 53' VAN:

Please give us your minimum cents per mile information. We understand that many factors will change this information, but this will give us a starting point.

Areas (ZONES) of the USA you like to travel - Please circle all that apply

Northeast (CT, DE, MA, ME, NH, NJ, NY, PA, RI, VT)

Midwest (IA, IL, IN, KS, KY, MI, MN, MO, MT, NE, ND, OH, SD, WI)

Southeast (AL, FL, GA, MD, MS, NC, sc, TN, VA, WV)

Southwest (AR, AZ, LA, NM, OK, TX)

West (AK, AZ, CA, co, ID, NM, NV, OR, UT, WA, WY)

NOTE: When returning the Dispatcher Packet, which includes the completed Dispatcher Agreement, the Carrier Profile and the Limited Power of Attorney, please include COPIES of your MC Authority Letter (Certificate), Certificate ofInsurance (C.O.I, and W9. If you are working with a factoring company, please also include a copy of factoring company's credit application so that they can run the credit on the brokers and send a Notice of Assignment (N.O.A if the credit is favorable. Thank you.