Must be completed by an Officer or Authorized Company Representative.

Carrier Region

Northeast: Maine, Vermont, New Hampshire, Rhode Island, Massachusetts, Connecticut, New York, New Jersey, Delaware, Maryland, Virginia, Pennsylvania (East of Altoona, PA), Quebec, New Brunswick, Newfoundland and Labrador, Nova Scotia, Prince Edward Island

Midwest: Michigan, Ohio, Indiana, Illinois, Kentucky, West Virginia, Pennsylvania (West of Altoona, PA), Ontario

Southeast: Tennessee, North Carolina, South Carolina, Georgia, Florida

South Central: Texas, Oklahoma, Arkansas, Louisiana, Mississippi, Alabama

Great Plains: Wisconsin, Minnesota, Iowa, Missouri, North Dakota, South Dakota, Nebraska, Kansas, New Mexico, Colorado, Utah, Wyoming, Idaho, Montana

West Coast: Washington, Oregon, California, Nevada, Arizona, British Columbia, Alberta, Saskatchewan, Manitoba, Yukon, Northwest Territories, Nunavut

Carrier Name

Trade D/B/A Names

Contact Name

Dispatchers

Phone (Toll-Free) #

Phone (Local) #

Phone (After-Hours) #

Fax #

Document Fax #

Remit to or Factoring Company

Contact Name

Remit to Phone #

Billing Fax #

Safety Contact

State of Incorporation or Organization

MC #

DOT #

Federal EIN #

FMCSA Rating
SatisfactoryConditionalUnsatisfactoryNot Rated

If FMCSA rating is Conditional, Not Rated, or recently changed, please explain:

Max Net Cargo Weight (lbs)

Provide advances (ComChecks) to drivers/office for operating expenses (fuel, tolls)?
YesNo

Provide advances (ComChecks) to your drivers for Lumper fees?
YesNo

Vans #

Reefer #

Flatbead #

Bonded?
YesNo

HazMat Certified?
YesNo

SmartWay Certified?
YesNo

Canada?
YesNo

Mexico?
YesNo

Intrastate?
YesNo

Warehousing?
YesNo

EDI Tracking?
YesNo

Drop Pools?
YesNo

Name

Title

Email

By checking this box, I hereby digitally sign for and verify that all information provided in this Carrier Profile is complete and accurate to the best of my knowledge and belief.