Date Today *

CLIENT'S INFORMATION

Client's Name *

Client's Phone Number *

Client's Email Address *

Client Type *

LOAD INFORMATION

Point of Contact Name *

Point of Contact Number *

Customer's Load Number *

Quaker Load Number *

Equipment Type *

Asset Number *

Asset Type *

If Others, specify

Asset Size *

If Others, specify

Weight (in lbs.) *If in kgs, multiply the value by 2 to convert into lbs* *

Is it overweight? *

If yes, did we get permits? *

Commodity *

Does this load have any special endorsement or requirements? *

If yes, what is the customer's special endorsement or requirement?

Does this load require a seal number *

Seal Number *

Customer Reference *

Type of Freight *

Motor Carrier *

MC Number *

Has a credit check been done? *

SCAC Code *

ETA (in number of days) *

Does this load have FSC? *

Will this load require storage? *

* If yes, please remember to deduct $30 per day

* Mandatory deduction of 1 day of storage

Can this customer deduct anything from the rate due to any nature of negligence? *

If yes, please specify WORD FOR WORD:

Original Load Pay *

Driver's Load Pay (minus 30% and storage) *

Upload Pictures (ie., ratecon, BOL or any other important documents) *

Expected Time of Mission Completion (# of days) *

Does this mission have multiple drops? *

PICK UP DETAILS

Shipper Pickup (Stop 1) *

Picking up from a port? *

If yes, what port?

Expected Date of Pickup *

Shipping/Receiving Hours *

Appointment Required at Pickup *

Appointment Time at Pickup *

AM or PM? *

Contact Name (Pickup) *

Contact Number (Pickup) *

Pickup Instructions *

Shipper References *

DELIVERY DETAILS

Consignee Delivery (Stop 2) *

Expected Date of Delivery *

Shipping/Receiving Hours at Delivery *

Appointment Required at Delivery *

Appointment Time at Delivery *

AM or PM? *

Contact Name (Delivery) *

Contact Number (Delivery) *

Delivery Instructions *

Consignee References *

DRIVER'S INFORMATION

Driver's First Name *

Driver's Last Name *

Driver's Contact Number *

Driver's Email Address *

Driver's Truck Number *

Driver's Vehicle License Tag *

Name of person completing this form *

I certify that all information provided is accurate and complete.