PAYMENT - ACH
Freight Broker
*
Please Select
Selmy G.
Alfredo M.
Angel N.
Angel R.
Shipment ID / BOL#
*
CARRIER INVOICE
*
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Cancel
of
POD (Must be SIGNED and DATED)
*
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Cancel
of
LUMPER RECEIPT (IF APPLICABLE)
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Cancel
of
RATE CONFIRMATION
*
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Cancel
of
VOIDED CHECK OR BANK VALIDATION
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Not required but recommended to ensure timely payment
Cancel
of
Pick Up Date
*
-
Month
-
Day
Year
Delivery Date
*
-
Month
-
Day
Year
CARRIER NAME
*
MC#
*
Email Address
*
example@example.com
Contact Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Name of Bank
*
Account Holder Name
*
Account Number
*
9-Digit Routing Number
*
FOR INTERNATIONAL ACCOUNTS: SWIFT CODE REQUIRED
SWIFT CODE
For Wires - Account Holder Address is Required
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Type of Account:
*
Personal
Business
Other
REMAINING BALANCE
*
*Will be verified*
Net Terms
*
Standard Net 30
Quick Pay (Net 2) 5% Fee
Processing Method
*
Standard Ach (free)
Wire ($25 Fee)
Same Day ACH (1% Fee)
Form Completed By:
*
First Name
Last Name
Title
*
Date
*
-
Month
-
Day
Year
Submit
Should be Empty: