CARRIER PROFILEInstructions: Please complete this form giving us all the information. The better informed we are, the better we will be able to assist you. This form should be updated at any time by notifying us. This information is for our use only and will not be released to any third party without your express written permission.1. CARRIER INFORMATIONPlease fill the name of the companyPlease fill in the company's addressField is required!- select a state -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingField is required!Field is required!Please enter contact personField is required!Please enter company email addressPlease enter fax numberPlease enter motor carrier numberField is required!Please enter DOT NumberField is required!Please enter EIN/SS#Field is required!2. EQUIPMENT SECTIONNUM. OF TRUCKS:-+Field is required!Company:-+Field is required!Owner Operator:-+Field is required!NUM. OF TRAILERS:-+Field is required!VAN:-+Field is required!REEFER:-+Field is required!FLATBED:-+Field is required!OTHER:-+Field is required!2. TRUCK & DRIVER(s) INFO:TRUCK #:Field is required!Field is required!Field is required!Field is required!Field is required!Field is required!Field is required!TRAILER #:Field is required!Field is required!Field is required!Field is required!Field is required!Field is required!Field is required!TYPE:Field is required!Field is required!Field is required!Field is required!Field is required!Field is required!Field is required!YEAR:Field is required!Field is required!Field is required!Field is required!Field is required!Field is required!Field is required!DRIVER:Field is required!Field is required!Field is required!Field is required!Field is required!Field is required!Field is required!DRIVER'S PHONE #:Field is required!Field is required!Field is required!Field is required!Field is required!Field is required!Field is required!3. SERVICE AREAS OF OPERATION (please check all that apply)ALARAZCACOCTDEFLGAIAIDILINKSKYLAField is required!MAMDMEMIMOMNMSMTNC NDNENHNJNMNVNYField is required!OHOKORPARISCSDTNTXUTVAVTWAWIWVWYField is required!4. RATE OF HAUL INFORMATIONPlease provide us your ideal (reasonable) rate information. We understand that many factors will change this information, but this will give us a starting point.IDEAL MILE RATEField is required!Field is required!Field is required!Field is required!5. FACTORING INFORMATIONIf you use factoring service, please provide the following information. This will ensure that we only use brokers approved by your factoring company.Field is required!Field is required!Field is required!Field is required!- FACTORING STATE -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming--Select State--Field is required!Field is required!Field is required!Field is required!Field is required!6. INSURANCE INFORMATIONPlease provide us with your insurance contact information, where we can request certificate of insurance with specific holders. (i.e. brokers and/or shippers) (***NEED COPY OF CERTIFICATE OF INSURANCE***)Field is required!Field is required!Field is required!Field is required!Enter Name of Contact PersonField is required!- select a state -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingField is required!Field is required!Please enter your company's phone numberPlease enter email address7. REFERRALPlease refer us three (3) Owner Operators who you believe might benefit from our service.Field is required!Field is required!Field is required!Enter Name of Contact PersonEnter Name of Contact PersonEnter Name of Contact Person8. ADDITIONAL INFORMATIONPlease use the section bellow to better describe your company. Include special terms and conditions of most importance and everything we have to consider while searching and taking the loads for you.Field is required! <a href="http://britjen.com/howtos/video/HowToSaveSignature.mp4" target="_blank"><img decoding="async" alt="" src="http://britjen.com/images/content/HowToSaveSignature.png" width="300"></a><br /> <br /> <iframe src="https://nosbiz.com/signature/clients/driverprofile" width="700" height="473"></iframe>Submit
