Dispatcher Questionnaire
Company Name
blanks
Name
First Name
Last Name
DBA (If applicable)
Physical Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Number
Please enter a valid phone number.
Format: (000) 000-0000.
Secondary Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Emergency Contact Name
First Name
Last Name
Emergency Contact
Please enter a valid phone number.
Format: (000) 000-0000.
Website (If Any)
DOT #
Motor Carrier #
SSN/EIN
TWIC CARD
Please Select
Yes
No
Hazmat Certification (If any please provide Hazmat Certification PDF & Training Cert)
Please Select
Yes
No
Equipment (All Flatbeds must have their own securement equipment to include
48" Van/Refeer
53" Van/Refeer
Box Truck
Flatbed
Step Deck
Hot Shot
Other
Check all that Apply
Air Ride
Pallet Jack
Dolly
Straps/Binders
Tarps
Lift Gate
Dock High
PPE Gear
Truck #
Trailer #
Max Load Weight (comments)
Lanes you like to Travel (Will discuss over the phone as well)
Cost Per Mile (Total Month Expenses/Mile per month + Average cost of 1 gallon of fuel/Miles per Gallon your truck average = Cost per Mile) "Worksheet can be provided"
Factoring Company (to ensure we deal with Brokers Only approved by your company)
Factoring Company Phone #
Please enter a valid phone number.
Format: (000) 000-0000.
Factoring Email
example@example.com
Website (For Factoring)
Trailer width
Trailer Dimension (Box Truck, VANs & Refeers ONLY L x W x H)
Factoring Company Remittance Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insurance Company
Insurance Agent Name
First Name
Last Name
Insurance Agent Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Insurance Agent Email(For Certification Requests)
example@example.com
Factoring Company User Name
Submit
Should be Empty: