Grade A Logistics Application Date:Select a dateField is required!Field is required!Legal Name of CompanyField is required!Field is required!Registered Trade Name (D.B.A):Field is required!Field is required!Your AddressField is required!Field is required!Mailing Address:Your AddressField is required!Field is required!CityField is required!Field is required!- select a state -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonMarylandMassachusettsMichiganMinnesotaMississippiMissouriPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming- select a state -Field is required!Field is required!ZipcodeField is required!Field is required!Authorized Contact:Field is required!Field is required!Title:Field is required!Field is required!Email Address:Your E-mail AddressField is required!Field is required!Phone:Your Phone numberField is required!Field is required!Fill in email to send insurance certificate request to your insurance company:Field is required!Field is required!Federal Tax ID #:Field is required!Field is required!MC #:Field is required!Field is required!US DOT#:Field is required!Field is required!- select a option -YesNo- select a option -Field is required!Field is required!Driver informationDriver:Field is required!Field is required!Truck #:Field is required!Field is required!Phone #:Field is required!Field is required!W-9 (must be signed and dated)Upload your documents...Field is required!Field is required!Operating Authority and DOT CertificateUpload your documents...Field is required!Field is required!I agree to the Carrier Workers' Compensation Insurance WaiverI agree to the Broker/Contract Carrier ContractI have been given the option to view/print the Grade A Logistics Setup PacketField is required!Field is required!$100,000 Regular Cargo Insurance Required.$1,000,000 General Liability Required.$1,000,000 Automobile/Public Liability Required.$150,000 Refrigerated Cargo Coverage.Payment delivery method- select a option -EFS Check (Fee: 5% of Invoice)ACH to your Bank Account Next Day (Fee: 3% of invoice)ACH to your Bank Account 30 Days (Free)- select a option -Field is required!Field is required!AccountField is required!Field is required!Account Type:- select a option -SavingsChecking- select a option -Field is required!Field is required!Account Number:Field is required!Field is required!Routing Number:Field is required!Field is required!Attach a voided check:Upload your documents...Field is required!Field is required!Select Office:- select a option -Huntingburg, INIndianapolis, INChampaign, IN- select a option -Field is required!Field is required!SignatureField is required!Field is required!Submitting this form with your electronic signature binds you to the agreements listed aboveSubmit
