Carrier Registration

• Company Information:

• Company Name*
• Company Type*Select One (Required)CorporationLimited Liability Company (LLC)PartnershipSole Proprietorship
• Equipment Type (Check all that apply – Required)*
  • 
    Van
  • 
    Flat
  • 
    Cargo
  • 
    Reefer
• Tax Identification Number (Required)*
• MC*
• USDOT*

• Insurance:

• Liability Amount ($)*
• Expiration Date*
  
  MM slash DD slash YYYY
  
• Cargo Amount ($)*
• Expiration Date*
  
  MM slash DD slash YYYY
  

• Dispatch Address:

• Street Address*
• Address Line 2
• City*
• State/Province*State/Province (Required)AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland & LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon
• Zip*
• Country*Please Select (Required)United StatesCanada

• Contacts:

• Dispatch Contact Name*
  
  First
  
  Last
• Title*
• Telephone*
• Fax
• Dispatch Contact Email*
  
  Enter Email
  
  Confirm Email
• Secondary Contact Name
  
  First
  
  Last
• Title
• Telephone
• Fax
• Secondary Contact Email
  
  Enter Email
  
  Confirm Email

• Contract:

• • 
    Check this box if same as Dispatch Contact above
• Name of Person Signing the Agreement*
  
  First
  
  Last
• Title*
• Name of Person Signing the Agreement Email*
  
  Enter Email
  
  Confirm Email

• Accounts Receivable Address:

• • 
    Check this box if same as Dispatch Address above
• Billing Address*
• Billing Address Line 2
• City*
• State/Province*State/Province (Required)AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland & LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon
• Zip*
• Country*Please Select (Required)United StatesCanada

• Accounts Receivable Contacts:

• • 
    Check this box if same as Dispatch Contact above
• Account Receivable Primary Contact*
  
  First
  
  Last
• Title*
• Telephone*
• Fax
• Email*
  
  Enter Email
  
  Confirm Email
• • 
    Check this box if same as Secondary Contact above
• Accounts Receivable Secondary Contact
  
  First Name
  
  Last Name
• Title
• Telephone
• Fax
• Email
  
  Enter Email
  
  Confirm Email

• Upload Your Broker Packet:

• Required*
  Drop files here or
  Select files
  Max. file size: 125 MB.

  Please upload your Broker Packet . This packet should include the following: Certificate of Liability Insurance; Certificate of Federal Operating Authority; IRS Form W9; Notice of Assignment (if you are using a Factoring Company)

Δ