Clone of Same Day Courier Order Form

Same Day Courier Order Form

Submit your delivery request below. Orders outside service limits will not be accepted. Payment must be completed before dispatch unless COD is selected.
PICKUP INFORMATION

Enter details for where the package will be picked up.
Pickup Name*
Pickup Phone*
Please enter a valid phone number.
Pickup Email*
example@example.com
Pickup Time

Hour Minutes

AM/PM Option
Pickup Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Pickup Notes
DROPOFF INFORMATION

Enter details for where the package will be delivered.
Dropoff Name*
Dropoff Phone*
Please enter a valid phone number.
Dropoff Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Delivery Notes
PACKAGE DETAILS

Enter your package details. Maximum weight: 90 lbs. Maximum dimensions: 47 x 36 x 20 inches.
Weight (lbs)*
Length (inches)*
Width (inches)*
Height (inches)*
Service Type*
DISTANCE & PRICING

Distance and price are calculated automatically based on addresses and selected service.
Total Price with Fuel Surcharge (USD)
PAYMENT METHOD

Select your payment method. Payment must be completed before dispatch unless COD is selected.
Payment Method*

ZelleVenmoCOD (Cash on Delivery)
Zelle Payment Instructions
Send payment to: tbalihuta@gmail.com or 6319031644 or Thierry Balihuta. Memo must include: Dropoff Name + Street Name. Upload proof of payment below before submitting.
Venmo Payment Instructions
Pay via Venmo: https://venmo.com/u/Thierry-Balihuta. Memo must include: Dropoff Name + Street Name. Upload proof of payment below before submitting.
Proof of Payment Upload*

Cancelof
Cash on Delivery
If payment not made at Delivery, The package will be held for 1 week, then discarded.
AGREEMENT

You must agree to the terms and provide your signature to proceed.
East End Connect operates as an uninsured courier service. We do not carry cargo or shipment insurance coverage. By engaging our services, customers agree that East End Connect shall not be held responsible for loss, theft, damage, or delays arising during transport. Customers assume full responsibility for the items being shipped and are advised not to send high-value, fragile, or irreplaceable goods.
I agree*

I agree
Signature*

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East End Connect, a Nouchi PrintWorks Service - printing@nouchiprintworks.com
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Same Day Courier Order Form

PICKUP INFORMATION

DROPOFF INFORMATION

PACKAGE DETAILS

DISTANCE & PRICING

PAYMENT METHOD

AGREEMENT