Long_Drive

Carrier Application

Owners Name *
Carrier/Company Name *
Website URL
D/B/A (Doing Business As)
Address *
  City *
State *
Zip *
Contact Person (name(s)) *
Toll Free Phone #
Main Contact Number(s) *
Cell Number(s)
Fax Number(s)
 
Federal Authority
MC#
DOT#
SCAC#
 
Operating As (check one) *  Corporation LLC Partnership Sole Proprietor
Authority Type  Contract Common Broker Freight Forwarder
 
Equipment Information
Please indicate the type of equipment you have, and the number.
Van
Reefer
Flatbed
Step Deck
Check below if operating in all states, or indicate which states below if not operating in all states.
 Operating in ALL States States Operating In
 
Insurance
Insurance Agency
Agency Name *
Phone #
Fax #
Policy #
 
Message