New Authority Carrier Set Up Form

New Authority Carrier Set Up Form

Our New Authority Carrier Set-Up simplifies the process of connecting carriers with a trusted network of brokers who work with new authorities. We’ll sign you up with 10 reliable brokers ready to help you get your truck moving from day one!
Company Name*
Owner's Name*

First NameLast Name
Fed ID #*
DOT#*
MC#*
Company Phone *
Please enter a valid phone number.Format: (000) 000-0000.
Fax
If applicapleFormat: (000) 000-0000.
Company Email
example@example.com
Dispatch Contact*
Dispatch Phone*
Dispatch Email*
Claims Contact*
Claims Phone*
Claims Email*
example@example.com
Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address (If different from physical)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Remit Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Power Units (tractors)*
Equipment Type(s)*
Haz-Mat (must provide current HZ permit)Warehouse/CrossdockingTeam ServiceTow Away Service (Tractor only)Pallet ExchangeRefrigeratedCanadian (provide current authority for CN)Mexican (provide current authority for MX)Drop Trailer(s)Lift gate Truck(s)Produce CarrierLTL
SCAC Code (If applicable)
ELD Brand*
RMIS Code (If applicable)
Factoring Company Corporate Contact
Name, phone number, and email
Completed W9, Authority Letter, NOA or Voided Check, & COI*

Cancelof
Additional FilesEx: Hazmat permit, Diverse-owned Business Documentation, etc.

Cancelof
I hereby certify I am the owner of the company listed above and authorize Loyalty Dispatch & Logistics, LLC to represent me in carrying out the services I have acquired. I acknowledge that my state might mandate a state-specific power of attorney for Loyalty Dispatch & Logistics, LLC to operate at the state level. I commit to providing any supplementary information promptly (within 48 hours of request) and acknowledge that Loyalty Dispatch & Logistics, LLC holds no responsibility for inaccuracies or late fees due to delayed information. All communication will be conducted via email (dispatch@loyaltydispatchlogistics.com). I acknowledge the absence of a refund policy.(required)
Please type first and last name
Date

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My Products
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New Authority- Carrier Setup
Setup w/ 10 brokers that will let you haul on Day 1 of your active authority

$400.00 Quantity

Total

$0.00

Payment Methods

Debit or Credit Card

Choose from one of the PayPal options to make your payment.

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