Pick Up / Delivery Request Form

Contact Information Company Name Contact # Phone ext E-mail Address City State - AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PW PA RI SC SD TN TX UT VT VA WA WV WI WY ZIP Billing Information Billing Information Same as Contact Info Company Name Name Phone ext E-mail Address City State - AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PW PA RI SC SD TN TX UT VT VA WA WV WI WY ZIP

Pickup Location / Shipment Information Name Phone Company Address City State AKALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWY ZIP Pick up Date Pick up Time 12:0012:301:001:302:002:303:003:304:004:305:005:306:006:307:007:308:008:309:009:3010:0010:3011:0011:30 AMPM Notes

Terminal	Line	Container	Booking #	Cutoff date	Weight	Size	Type of Comm.	Loading Type
					- Less than 37,000 lbs Between 37,000 and 44,500 lbs More than 44,500 lbs	- 20 FT 40 FT 45 FT 48 FT DOMESTIC 53 FT DOMESTIC		- Live Load/Unload Drop & Pick Unsure/Quote All

Contact Information Company Name Contract # Phone ext E-mail Address City State - AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PW PA RI SC SD TN TX UT VT VA WA WV WI WY ZIP Billing Information Billing Information Same as Contact Info Company Name Name Phone ext E-mail Address City State - AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PW PA RI SC SD TN TX UT VT VA WA WV WI WY ZIP

Pickup Location Port - NJ NY Terminal MAHER TERMINAL APM TERMINAL COLUMBIA TERMINAL GLOBAL TERMINAL PNCT TERMINAL IRONBAUND TERMINAL INTERPORT TERMINAL CSX TERMINAL OTHER NYCT TERMINAL OTHER Line - Not Provided/Unknown Domestic Equipment Provider Alianca Lines Atlantic Container Line American President Lines Australia National Lines - ANL Bahri Bermuda Shipping CCNI China Shipping N.A. CMA-CGM COSCO Evergreen Shipping Great White Fleet Hamburg Sud Hanjin Shipping Hapag Lloyd Horizon Lines Hyundai Merchant Marine Independent Container Line K-Line America Maersk Lines Matson Navigation Mediterranean Shipping Co. MOL America Norasia (CSAV) NYK Line OOCL Pacific International Lines Safmarine Sea Star Line Seaboard Marine Shipping Company of India Trailer Bridge Tropical Shipping Turkon Lines United Arab Shipping U.S. Lines Wan Hai Lines Westwood Shipping Yang Ming Lines ZIM Integrated Shipping Comments Availible for Pick Up The Last Free Date Delivery Information Company Name Phone ext Address City State AKALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWY ZIP Delivery Date Appointment Time 12:0012:301:001:302:002:303:003:304:004:305:005:306:006:307:007:308:008:309:009:3010:0010:3011:0011:30 AMPM Notes

Container #	BOL #	Seal #	Weight	Size	Type of Comm	Other
			- Less than 37,000 lbs Between 37,000 and 44,500 lbs More than 44,500 lbs	- 20 FT 40 FT 45 FT 48 FT DOMESTIC 53 FT DOMESTIC

Common Accessorials (if known)
Tri Axle (Will be quoted on 20 FT over 37,000 lbs & subject to positioning charges)
Reefer
HAZMAT (Please provide documentation above)
Chassis Split/Positioning
Chassis Usage (If CPG is required to provide the chassis)
Pre-Pull (If CPG is required to pre-pull the container before delivery)

Rate	FSC	Chassis	Toll	Total