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Date
*
MM slash DD slash YYYY
Company
*
MC Number
*
DOT Number
Address
*
Street Address
City
State / Province / Region
ZIP / Postal Code
Phone
*
Extension
Do You Use a Factor?
*
Yes
No
Notice of Assisgnment
*
Please upload your Factor's Notice of Assignment Document
Max. file size: 50 MB.
Please indicate which of the following payment terms you would like to use. Your selection will remain your permanent payment term until the 3SIX5 Logistics, LLC team is notified in writing that you would like your terms to change. All pay terms begin the day 3SIX5 Logistics, LLC receives your complete and legible paperwork.
28 Days
– No fees – Check is mailed or payment direct deposited within 28 days of 3SIX5 receiving complete and legible paperwork. Please email invoice, rate confirmation and all delivery documentation to
[email protected]
. If original documents are required, please mail them.
7 Day Quick Pay
– A 3% service charge will be deducted from the gross truck rate. This is issued through either check or direct deposit. Make sure to write “7 Day Quick Pay” on your invoice.
Payment Terms Choice
*
I would like to use the following payment plan (outlined above):
28 Day - No Fees
7 Day Quick Pay - 3% Fees
Primary Contact Name
*
First
Last
Primary Contact Phone
*
Extension
After Hours Phone
*
After Hours Extension
Primary Contact Email
*
Fax
Do You Have A Single Carrier Packet File?
*
File must contain: W-9, Certificate of Liability, and Carrier Authority
Yes
No, My paperwork is in separate files.
W-9
*
Max. file size: 50 MB.
Certificate of Liability Insurance
*
Max. file size: 50 MB.
Carrier Authority
*
Max. file size: 50 MB.
Carrier Packet
*
Max. file size: 50 MB.
Your Insurance Agent's Name
*
Your Insurance Agent's Email
*
Your Insurance Agent's Phone Number
Your Insurance Agent's Fax Number
Your Company Name (as on the certificate)
*
Enter your trucking company's info here, as it reads on your insurance certificate.
Address of Your Company (as on the Certificate)
*
Enter your business address as it reads on the Certificate of Insurance
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