CUSTOMER INFORMATION
Company Name:
Address:
Unit/Suite#:
City:
Province/State:
Postal/Zip Code:
Name of Contact:
Telephone Number:
SHIPMENT INFORMATION
Shipper:		Consignee:
Telephone:		Telephone:
Contact:		Contact:
Drop Trailer	Live Load	Drop Trailer	Live Load
Date:	Date:	Date:	Date:
Time:	Time:	Time:	Time:
Pickup upon completion of load		Pickup upon completion of load
Date:		Date:	Brico to advise date & time
Time:		Time:
Description/Commodity:		Special Instructions / Comments:
FTL or Pieces		Domestic North America International
Piece Count:		Dimensions in Inches: L W H
Weight:		Equip: Flat Van Reefer   Straight Truck Other (specify)
Ref # / P.O. # / Pick No.