National Carrier Intake Form

1
Business Name* This field is required.
2
MC Number* This field is required.
3
USDOT Number* This field is required.
4
Equipment Type* This field is required.
Please Select
Please Select
Dry Van
Reefer
Box Truck
Flatbed
Heavy Equipment Operator (RGN's or other)
5
Years in Authority* This field is required.
Please Select
Please Select
Less than 1 year
1-2 years
3-5 years
6-10 years
11+ years
6
Violation Count* This field is required.Reported Safety Violations (Last 24 Months)
Please Select
Please Select
0-2
3-4
5+
All safety data will be cross-referenced with the FMCSA Safety and Fitness Electronic Records (SAFER) system.
7
Do you have a valid CDL or Driver's License?* This field is required.
Yes
No
8
Do you have any DUI/DWI history?* This field is required.
Yes
No
9
Disqualification Notice
10
Which program are you applying for?* This field is required.
Please Select
Please Select
Standard (8%)
New Authority (10%)
Rescue Program (0%)
11
Final Repair/Tow Invoice (Required for Rescue Program applicants)
Drag and drop files here
Select files to upload
Max. file size: 10.0MB
Cancelof
12
Upload a valid Driver’s License* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.0MB
Cancelof
13
Certificate of Insurance ($100k Cargo / $1M Liability)* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.0MB
Cancelof
14
FMCSA Authority Letter* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.0MB
Cancelof
15
Signed W-9 Form* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.0MB
Cancelof
16
Equipment Photo (Truck/Trailer)* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.0MB
Cancelof
17
Terms and Conditions & Load Integrity Protocol (4-point photo requirement):

1. Preload, mid-load, and post-load photos must be submitted for every shipment.
2. All cargo must be secured and verified before departure.
3. Any damage or incident must be reported immediately.
4. Failure to comply may result in removal from the program.

Please review in detail before signing below.
18
Signature (Legally Binding E-Signature)* This field is required.
19
I agree to the 7-day performance trial and automatic enrollment.* This field is required.
I agree to the 7-day performance trial and automatic enrollment.
20
ROUTEHAUL LOGISTICS MANAGEMENT AGREEMENT: RATE & GRADUATION TERMS
1. SCOPE OF AGENCY The Carrier hereby appoints Routehaul High Desert Logistics Partners ("Agent") as their authorized logistics manager. This Limited Power of Attorney authorizes the Agent to negotiate freight, execute Broker-Carrier agreements, and sign Rate Confirmations in the Carrier’s name.

2. COMMISSION TIERS & GRADUATION PROTOCOL All partnerships begin at a 10% Commission (except for the initial two loads of a verified 'Rescue'). Graduation to the 8% Elite Standard Rate is automatic based on the following authority status:

STANDARD / EXPERT: 10% commission for a 7-Day Performance Trial. Automatic drop to 8% on Day 8.
RE-ENTRY AUTHORITY (<3 Violations): 10% commission for a 30-Day Probationary Period. Automatic drop to 8% on Day 31.
NEW AUTHORITY (<6 Months Active): 10% commission for a 90-Day Safety Fast-Track. Automatic drop to 8% on Day 91.
RESCUE PROGRAM: 0% commission for the first two (2) loads (requires verified repair invoice), followed by the 7-Day Performance Trial at 10%, then transitioning to 8%.
3. PERFORMANCE REQUIREMENTS FOR RATE REDUCTION To qualify for the automatic rate drop to 8%, the Carrier must maintain:

Zero (0) new safety violations during the probationary period.
100% Compliance with the Routehaul 4-Point Load Integrity Protocol (Photo verification).
Note: Failure to meet these standards may result in an extension of the 10% rate or termination of service.
4. AUTOMATIC ENROLLMENT & TERMINATION Carrier acknowledges that if no written notice of termination is provided by the end of the initial 7-day trial, they are automatically enrolled into their respective graduation path. Following the trial, a 7-day written notice is required for termination by either party.
Should be Empty: