Secure Courier Service Request
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SECTION 1: CLIENT INFORMATION
Full Name
First Name
Last Name
Company Name (If Applicable)
Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Preferred Method of Communication
Please Select
Call
Text
Email
Is this a one-time delivery or recurring service?
Please Select
One-Time
Weekly
Monthly
On-Demand Contract
Not Sure yet
SECTION 2: PICKUP DETAILS
Pickup Date
-
Month
-
Day
Year
Date
Pickup Time Window
Please Select
ASAP (within 2 hours)
Same Day
Scheduled (enter time)
Pickup Time
Hour Minutes
AM
PM
AM/PM Option
Pickup Address
Full address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact person at pickup:
Special Pickup Instructions:
SECTION 3: DELIVERY DETAILS
Full address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Delivery Deadline
Please Select
No Rush
Same Day
Before specific time (enter time)
Signature required?
Please Select
Yes
No
Photo confirmation only
SECTION 4: PACKAGE INFORMATION
What are you delivering?
Legal Documents
Mecical supplies
Pharmaceuticals
Lab specimens
Sensitive paperwork
Small high-value goods
Other (describe)
Other (describe)
Is the item confidential?
Please Select
Yes
No
Estimated Weight
Please Select
Under 5 lbs
5-20 lbs
20-50 lbs
Over 50 lbs
Dimensions (if known)
Does the item require:
Please Select
Temperature control
Fragile handling
Chain of Custody Documentation
ID Verification upon delivery
None
SECTION 5: SECURITY & LIABILITY
Declared Value of Contents
Are contents insured?
Please Select
Yes
No
Information will be provided
Any hazardous materials?
Please Select
Yes
No
(if Yes-Describe)
Describe
SECTION 6: PAYMENT
Preferred Payment Method
Please Select
Zelle
ACH
Business Invoice
Credit Card
Cash (approved clients only)
Email
example@example.com
Billing Address (if different)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
SECTION 7: AGREEMENT
I confirm that all information provided is accurate and I understand Via Lainez Express reserves the right to decline hazardous or prohibited items.
Please Select
Yes
No
Submit
Should be Empty: