Please acknowledge that you understand that you will be entering sensitive information.
*
I understand and acknowledge that I will be entering sensitive information.
I choose to manually exit this subhaul pack without submitting any information.
Please acknowledge that you understand that your digital signature will be accepted in place of your physical signature.
*
I acknowledge and understand that my digital signature will be accepted in place of my physical signature.
Company Name:
*
Owner's Name
*
Address
*
Street Address
Street Address Line 2
City
Zip Code
Postal / Zip Code
State
*
2 Letters Only
Federal ID #
*
SS#
*
CA#
*
DBE #
DBE Exp. Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Truck Make Primary
*
Truck Primary
*
Rows
YEAR
VIN NO. LAST 6
1.
Truck Make Secondary
Truck Secondary
Rows
YEAR
VIN NO. LAST 6
2.
13. Date of Signing
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Office Phone:
*
Format: 000-000-0000.
Dispatch Phone:
*
Format: 000-000-0000.
E-mail:
*
example@example.com
Owner's Signature
*
US DOT #
*
MC #
*
Owner's Signature
*
Choose 1 Option
*
A) I am a Corporation/LLC/Partnership. I am the only driver that receives a payroll check and have declared myself exempt from Workers' Compensation coverage.
B) My company is a Corporation/LLC/Partnership, and all drivers are partners and are declared exempt from Worker's Compensation coverage. List the names of the partners/owners below
C) My company is a Corporation/LLC/Partnership and I have drivers as employees and will obtain Workers' Compensation coverage. I understand that only the owner, [enter owner's name below], is approved to work on Anytime Dispatching, Inc. projects. My employees are my sole responsibility as stated in Section 19 of the Broker-Carrier Contract.
Partner 1 Name [Option B ONLY]
Partner 1 % of Ownership [Option B ONLY]
Partner 1 Signature [Option B ONLY]
Partner 2 Name [Option B ONLY]
Partner 2 % of Ownership [Option B ONLY]
Partner 2 Signature [Option B ONLY}
Partner 3 Name [Option B ONLY]
Partner 3 % of Ownership [Option B ONLY]
Partner 3 Signature [Option B ONLY]
Owner's Name [Option C ONLY]
Owner's Signature
*
Name of Registered Owner
*
Name of Driver
*
Driver License #
*
What Type of Dump Truck Do You Own?
*
Super10/SuperTag/Bottom/End/etc
MCP #
*
Truck License #
*
Owner's Signature
*
Choose 1
*
13% Broker's Fee (Direct Deposit initiated on the 7th of every month, physical checks on the 15th)
15% Broker's Fee (Paid every 2 weeks, Diect Deposit only)
Owner's Signature
*
Owner's Signature
*
Business Title of Signer
*
DIR Username/Email
*
Required Document Uploads
Current Motor Carrier Permit
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Current Class A or B
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Signed W-9
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Proof of Valid Medical
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Random Drug Enrollment Certificate
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Current Vehicle Registration(s)
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Proof of Valid DIR
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Please acknowledge the following:
*
I acknowledge that I have reviewed the full 15-page Sub-haul Pack and agree that the information I have provided above will be mapped directly onto that legal document. I also acknowledge that I can, and should, preview and print the document for my records before submitting.
Preview PDF
Print
Save
Submit
Submit
Should be Empty: