Truck Dispatching Carrier Set-Up
Carrier Profile
COMPANY NAME / DBA
*
US DOT#/MC#/INTERSTATE PERMIT
*
EIN
*
Company Phone Number
*
Please enter a valid phone number.
What is your truck number?
*
Hour of services logs (Last 7 Days)
*
N/A is not applicable
Truck Specification (Make, Model, Year)
*
Trailer type and dimensions
*
Any special equipment or capabilities
What is your trailer number?
*
When did you receive your authority?
*
-
Month
-
Day
Year
Date
CARRIER NAME
*
First Name
Last Name
CARRIER EMAIL
*
example@example.com
CARRIER ADDRESS
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
INSURANCE COMPANY
*
INSURANCE CONTACT NAME
*
INSURANCE PHONE #
*
Please enter a valid phone number.
NAME OF FACTORING COMPANY (If Applicable)
Make sure to send NOA for payment
What is the name of your bank? Provide Address: (This is for Quick Pay Payment)
Bank Name
Street Address Line 1
City
State / Province
Postal / Zip Code
Bank Phone #
Please enter a valid phone number.
HOW MANY TRUCKS ARE IN YOUR FLEET?
Please Select
1
2
3
4
5
6
7
8
9
HOW MANY DRIVERS?
Please Select
1
2
3
4
5
6
7
8
9
EQUIPMENT TYPE
*
Please Select
Box Truck
Dry Van
Flatbed
Hot Shot
Power-Only
Reefer
Stepdeck
What type of trailer do you have? ex: 53' DV, 53' Reefer or 48'/53' Flatbed, 26' Box Truck, Hotshot,etc.
Choose type of operation:
Please Select
Local
OTR
Regional
What States do you prefer to drive to? (Please check all that apply)
*
Northeast (NY, NJ, CT, MA, etc.)
Midwest (MT, OH, KY, IN, IL, WI, etc.)
Southeast (FL, GA, LA, AL, etc.)
Southwest (TX, NM, etc.)
West (CA, AZ, OR, NV, ID, etc.)
What areas of the country should we avoid?
*
How often do you want to be home?
*
Do you have a Standard Carrier Alpha Code (SCAC)?
Would you like to connect your ELD device for automated tracking?
If so please type in your ELD provider.
EDI format capability:
None
204
210
214
990
Does the trucks have the company logo at the back?
Yes
No
How did you hear about Silverback Dispatch and Logistics?
Other Documents Needed
Please upload copies of your W-9, MC AUTHORITY LETTER and CERTIFICATE OF INSURANCE, Add NOA (Notice of Assignment) if applicable. Also provide a copy of Driver's license and Voided check for Quick Pay setup.
MC Authority Letter
*
Browse Files
Drag and drop files here
Choose a file
Accepted file types: pdf, doc, png, jpg
Cancel
of
Valid Drivers License (Front and Back)
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
W-9
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Certificate of Insurance (Proof of Insurance - Cargo and Liability)
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
DOT Medical Certification
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Notice of Assignment (NOA) if factoring
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Upload a voided check for quick pay option:
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Upload most recent State/Federal Inspections?
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Please provide more details about that situation
Revoked date, reason, and date reinstated
Any Special Instructions?
Revoked date, reason, and date reinstated
Was there any previous history about your license being revoked?
*
Yes
No
Authorized Signature
*
Date of Submission / Effective Date
*
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: