DISPATCHER QUESTIONNAIRE
COMPANY NAME
FULL NAME
*
First Name
Last Name
DBA (If Any)
PERMANENT ADDRESS
*
PRESENT ADDRESS
*
PRIMARY PHONE NUMBER
*
Please enter a valid phone number.
Format: (000) 000-0000.
SECONDARY PHONE NUMBER
Please enter a valid phone number.
Format: (000) 000-0000.
EMAIL
*
example@example.com
EMERGENCY CONTACT NAME
*
EMERGENCY CONTACT PHONE NUMBER
*
Please enter a valid phone number.
Format: (000) 000-0000.
WEBSITE (If Any)
DOT #
MOTOR CARRIER #
SSN/EIN #
TWIC CARD
YES
NO
HAZMAT CERTIFICATION (If yes, please provide Hazmat Certification PDF and Training Certs)
YES
NO
ATTACHMENTS
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EQUIPMENT (All Flatbeds must have their own securement equipment to include tarps!!!)
*
48' VAN/REEFER
53' VAN/REEFER
FLATBED
STEPDECK
HOTSHOT
BOX TRUCK
OTHER
CHOOSE ALL THAT APPLY
Air Ride
Pallet Jack
Dolly
Straps/Binders
Tarps
Lift Gate
Dock High
PPE Gear
TRUCK #
TRAILER #
TRAILER LENGTH
TRAILER DIMENSIONS (Box Truck, VANs & Reefers ONLY LxWxH)
LANES YOU WILL LIKE TO TRAVEL (will be discussed over the phone as well)
MAX LOAD WEIGHT (Comments)
COST PER MILE (Total Monthly Expenses/Miles per month + Average cost of 1 gallon of Fuel/Miles per Gallon your Truck averages = Cost per Mile) *Worksheet can be Provided*
FACTORING COMPANY (to ensure we deal only with brokers that are approved by your company)
FACTORING COMPANY AGENT'S NAME (full name)
FACTORING COMPANY PHONE NUMBER
Please enter a valid phone number.
Format: (000) 000-0000.
FACTORING COMPANY EMAIL
example@example.com
WEBSITE (for factoring)
FACTORING COMPANY USERNAME
INSURANCE COMPANY
INSURANCE AGENT NAME
INSURANCE AGENT PHONE NUMBER
Please enter a valid phone number.
Format: (000) 000-0000.
INSURANCE AGENT EMAIL (for Certificate Requests)
example@example.com
CERTIFICATE OF INSURANCE
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AUTHORITY LETTER
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POA
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COMPLETED W9
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