Carrier Signup
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 our use only and will not be released to any third party without your express written permission.
PART 1: CARRIER GENERAL INFORMATION
COMPANY NAME
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
MC Number
PART 2: EQUIPMENT TYPES
Number and Type of Equipment: 53' VAN:
53' VAN
53' REEFERS
48'/53' FLATBED
POWER ONLY
Truck #'s
Trailer #'s
Cargo Van
Sprinter Van
Box Truck
Hotshot
Trailer Accessories for your specific equipment types (Dry Van, Reefer, and Flatbed)
OTHER TYPES
PLEASE LIST THE BROKERS THAT YOU ARE ALREADY SET UP OR APPROVED WITH BELOW
DISPATCH SPECIFICATIONS
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.
CENTS ($) PER MILE
MAX # OF DELIVERIES
DRIVER TOUCH (Y/N)
Mountains? (Y/N)
TOLLS? (Y/N)
Weight Limit
HOME TIME
TYPE OF ENDORSEMENTS
CLEARANCE TYPE: (TWIC, DBID, RAPID GATE, STA)
Areas (ZONES) of the USA you like to travel - Please circle all that applyNortheast (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)
Comments
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 of Insurance (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.
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