SHIPPER REGISTRATION FORM
Please complete this form to begin your business relationship with EZ Logistics Group
1. Company Information
Legal Company Name
*
DBA / Trade Name (if applicable)
Headquarters Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
DOT Number (if applicable)
Years in Operation
*
Type of Business
*
Please Select
Manufacturer
Distributor
3PL
Importer
Exporter
Other
Avg. Shipments/Month
*
Types of Freight You Ship
*
Please Select
Palletized
LTL (Less Than Truckload)
FTL (Full Truckload)
Refrigerated / Temperature Controlled
Hazmat (Hazardous Materials)
Expedited
Oversized / Overweight
High-Value Cargo
Automotive Parts
Medical Supplies
E-commerce / Parcels
Food & Beverage
Construction Materials
Paper / Packaging
Electronics
Other
If you selected "Other", please describe:
Frequent Pickup Zones
*
Please Select
Northeast (New York, New Jersey, Pennsylvania, Massachusetts, Connecticut, Rhode Island, Vermont, New Hampshire, Maine)
Southeast (Florida, Georgia, North Carolina, South Carolina, Alabama, Mississippi, Tennessee, Kentucky, West Virginia, Virginia)
Midwest (Illinois, Ohio, Michigan, Indiana, Wisconsin, Minnesota, Iowa, Missouri, North Dakota, South Dakota, Nebraska, Kansas)
South Central (Texas, Oklahoma, Louisiana, Arkansas)
Mountain States (Colorado, Utah, Arizona, New Mexico, Montana, Idaho, Wyoming, Nevada)
West Coast (California, Washington, Oregon)
Nationwide
Canada
Mexico
Other: ____________ (please specify)
If you selected "Other", please describe:
Frequent Delivery Zones
*
Please Select
Northeast (New York, New Jersey, Pennsylvania, Massachusetts, Connecticut, Rhode Island, Vermont, New Hampshire, Maine)
Southeast (Florida, Georgia, North Carolina, South Carolina, Alabama, Mississippi, Tennessee, Kentucky, West Virginia, Virginia)
Midwest (Illinois, Ohio, Michigan, Indiana, Wisconsin, Minnesota, Iowa, Missouri, North Dakota, South Dakota, Nebraska, Kansas)
South Central (Texas, Oklahoma, Louisiana, Arkansas)
Mountain States (Colorado, Utah, Arizona, New Mexico, Montana, Idaho, Wyoming, Nevada)
West Coast (California, Washington, Oregon)
Nationwide
Canada
Mexico
Other: ____________ (please specify)
If you selected "Other", please describe:
Do You Currently Work with a Freight Broker?
*
Yes
No
What Do You Expect from a Freight Broker?
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2. Primary Contact Information
Name
*
First Name
Last Name
Job Title
*
Direct Phone Number
*
Please enter a valid phone number.
Corporate Email
*
example@example.com
Are You Authorized to Make Transportation Decisions?
*
Yes
No
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3. Shipping & Operations Details
Pickup Hours
*
Hour Minutes
AM
PM
AM/PM Option
Delivery Hours
*
Hour Minutes
AM
PM
AM/PM Option
Average Loading Time
*
Please Select
Less than 30 minutes
30 – 60 minutes
1 – 2 hours
2 – 3 hours
More than 3 hours
It varies – depends on the load
Average Unloading Time
*
Please Select
Less than 30 minutes
30 – 60 minutes
1 – 2 hours
2 – 3 hours
More than 3 hours
It varies – depends on the load
Is an Appointment Required?
*
Yes
No
Do You Require a Pallet Jack or Ramp?
*
Yes
No
Any Access Restrictions?
*
Please Select
Limited dock availability
Liftgate required
Appointment required
Limited hours of operation
Residential area
Gated facility (access code or security check needed)
Height restrictions
Weight restrictions
No overnight parking
Limited turning space
Requires TWIC card
Union-only labor site
Other: ____________ (please specify)
If you selected "Other", please describe:
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4. Billing & Payment Information
Preferred Payment Method
*
Please Select
ACH
Check
Credit Card
Payment Terms
*
Please Select
Net 7
Net 15
Net 30
Billing Contact Name
*
First Name
Last Name
Billing Contact Email
*
example@example.com
Billing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do You Accept Electronic Signatures on BOLs?
*
Please Select
Yes
No
Do You Use EDI Systems?
*
Please Select
Yes
No
Do You Require PODs Before Payment?
*
Please Select
Yes
No
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5. Upload Documents
(Required Attachments)
W9 Form
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Shipping Instructions or SOP
Browse Files
Drag and drop files here
Choose a file
if available
Cancel
of
List of Frequent Pickup/Delivery Locations
Browse Files
Drag and drop files here
Choose a file
if available
Cancel
of
Contract or NDA
Browse Files
Drag and drop files here
Choose a file
if available
Cancel
of
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Authorization & Confirmation Statement
I hereby confirm that all information provided in this form is complete, accurate, and truthful to the best of my knowledge. I further certify that I am legally authorized to submit this form and act on behalf of the company listed above. By submitting this form, I acknowledge and accept that: The information provided may be used by EZ Logistics Group to establish a business relationship. I am responsible for ensuring the accuracy and validity of the details shared. Any misrepresentation or falsification of information may result in a delay or termination of the onboarding process .I agree to receive communication related to transportation services, account setup, and future business correspondence.
I agree and confirm the above statement.
Signature
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