Date:

Company Name:

Your Name:

Telephone:

E-mail:

Repeat E-mail:

Origin

City:

State:

5 digit Zip:

Trade Show?:

Yes

No

Dock Available?:

Yes

No

Destination

City:

State:

5 digit Zip:

Trade Show?:

Yes

No

Dock Available?:

Yes

No

Product:

Number of Pieces:

Total Estimated Weight:

Size of Pieces:

Please Use Inches

Pc. 1 (L x W x H):

Weight:

X

X

Pc. 2 (L x W x H):

Weight:

X

X

Pc. 3 (L x W x H):

Weight:

X

X

Pc. 4 (L x W x H):

Weight:

X

X

Pc. 5 (L x W x H):

Weight:

X

X

Pc. 6 (L x W x H):

Weight:

X

X

Pc. 7 (L x W x H):

Weight:

X

X

Pc. 8 (L x W x H):

Weight:

X

X

Pc. 9 (L x W x H):

Weight:

X

X

Pc. 10 (L x W x H):

Weight:

X

X

Enclosed Van Required?:

Flatbed Required?:

Yes

No

Yes

No

Is Shipment Cartoned/Crated/Skidded?:

Yes

No

Additional Insurance Requested For The Declared Value of$:

Residential Pick Up:

Yes

No

Residential Delivery:

Yes

No

Stairs::

Yes

No

Requires Liftgate?:

Yes

No

Special Instructions: