Dispatch Registration Form

Dispatch Sign Up

Top Tier Start Up Assistance & Dispatch Services
Contact Name *

First NameLast Name
Company Name or DBA*
Date Of Birth*
Contact Number*
E-mail*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
MC Number (If you have your own authority)
US DOT# (We can help with this if you do not have it)
EIN Federal Tax ID (This is critical-We will be handling all of your W9 paperwork for shippers )
Truck (Year -Make-Model-GVWR) If multiple trucks list on seperate line
Equipment*

Flat BedReeferBox Truck53' Dry Van53' Dry Van Power Only
Preferred Service Area*

OTR (NO RESTRICTIONS)OTR (LiMITED)NortheastSoutheastMidwestNorthwestSouthwest
Desired Weekly Gross Income*

Under $2K$2K-$3K$3K-$4K$5K-$6K$6K-$7KAbove $7K
Does driver/s have additional endorsements?*

YesNo
Do all drivers have clean MVR?*

YesNo
Is the company "MC" number active for a minimum of 6 months?*

YesNo
Are you seeking dedicated dispatch services with 1 company exclusively?*

YesNo
How many power units are in the fleet?*

12345+
How many trailers are in the fleet?*

12345+
What is your current biggest area of opportunity regarding dispatching and/or back office support?
Trailer (Length-GVWR) If multiple trucks list on separate line
Regional Area of Preference
Current Factoring Company (If not using a currently, We can help set up a program)
Insurance Company (Need Company name, Agent & Phone Number)-This is critical for us to book your freight
Reference #1-(NOTE)We do NOT require references...We help new companies get started. BUT, Many Brokers want references, List what you have.
Ref #2 Be sure to include phone and email for your references
Reference #3 -We can be one of your references !
If you are not the driver of the truck-Please list driver name and cell number-(It is critical for dispatch)
What should we know ? Tell us about anything that is important to you and your operations. WE ARE HERE TO SERVE YOU !
How did you hear about us?*
IMPORTANT NOTE: You must EMAIL a copy of your MC Authority (or DOT), and a copy of your Insurance to info@purescreeningsolutions.co to complete your set-up process. If you can not scan and email, please FAX your MC Authority and Insurance to 352-451-4492.

WE CAN NOT BOOK FREIGHT WITHOUT THIS INFORMATION.

Welcome to the PURE DISPATCH TEAM! We look forward to working with you! Please be sure to contact us with ANY questions... While it is our mission to MAXIMIZE your earnings and keep you on the best routes. We build lasting relationships with everyone for the benefit of our drivers.

It is our goal to keep your company running smoothly with profitable and consistent freight for all carriers and drivers focused on the road.
List Referral Source or Code (Leave blank if you do not have a referral source)
I agree to have Pure Screening Solutions LLC, book my loads at the fee rate as shown in the "Dispatch Services" page. I further agree to pay my invoice weekly through paypal, Square or credit/debit card. I give full consent to Pure Screening Solutions LLC, team members to complete and sign documents as required to book loads. I further agree to "Hold harmless" Pure Screening Solutions LLC, Pure Screening Dispatch Services, and JSW Models & Productions LLC. *
By signing my signature, I agree to accept the terms above of this simple agreement. and I hereby authorize Pure Screening Solutions LLC, As my Dispatch Agent. You are not bound to a long-term contract.

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Dispatch Sign Up