HazMat LTL Shipment Form

HazMat LTL Shipment Form

Less than Truckload Request Form
Name of person placing request

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
PICKUP LOCATION
Multiple Pickup Locations (3 Max)
How Many Pickup Locations
Name Of Facility
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Person at Pickup Location

First NameLast Name
Phone Number
Please enter a valid phone number.
Do they have a Loading Dock?

YesNo
Forklift?

YesNo
Lift Gate Needed?

YesNo
Name Of Facility 2
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Person at Pickup Location

First NameLast Name
Phone Number
Please enter a valid phone number.
Do they have a Loading Dock?

YesNo
Forklift?

YesNo
Lift Gate Needed?

YesNo
Name Of Facility 3
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Person at Pickup Location

First NameLast Name
Phone Number
Please enter a valid phone number.
Do they have a Loading Dock?

YesNo
Forklift?

YesNo
Lift Gate Needed?

YesNo
DESTINATION FACILITY
Name of Facility
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
BILLING INFORMATION
Name of Company paying freight charges
Credit established with HazMat?

YesNo
If not, Credit Application must be completed, signed, and references attached for approval prior to pickup.
Application is available here: HazMat New Client Credit Application
SHIPMENT INFORMATION
D.O.T. Shipping Name
(as it will appear on the manifest or bill of lading)
Hazard Class
Non-Regulated?
Type of Containers

55 gal. drumscubic yard boxessupersacksOther
If Other
Number of Pieces to be loaded
Special Instructions
Should be Empty:

HazMat LTL Shipment Form

PICKUP LOCATION

DESTINATION FACILITY

BILLING INFORMATION

SHIPMENT INFORMATION