ONLINE FREIGHT BROKER BOND APPLICATION
      
BONDING AGENT:   MONIKA HANCOCK -1-800-977-9883 EXT. 103
               FOR AUTHORITY OR INSURANCE INQUIRY CALL 1-800-977-9884

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                                          COMPANY INFORMATION  

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NAME OF APPLICANT
(LEGAL NAME)  SHOW EXACTLY AS IT APPEARS IN OP-1 OR ON BROKER'S LICENSE.

ICC BROKERAGE MC #:   FEIN NO:   CORP REG. NO:
                            
           WRITE "PENDING" IF PENDING         WRITE "PENDING" IF PENDING                   WRITE "N/A" IF NOT APPLICABLE

FORM OF ORGANIZATION:  

STATE OF ORGANIZATION: COUNTY: COUNTRY:
For a U.S. corporation or LLC, give state or territory in which organization papers are filed. For a non U.S. corporation,
or LLC, give principal U.S. state or territory in which your firm is registered to do business as a foreign organization.
For a sole proprietorship or partnership, give state shown on Federal Motor Carrier Safety Administration Records.

LEGAL ADDRESS:

Street & Number or P.O. Box              City                                State                                  Zip
For corporation or LLC, give the address of the corporate (not BOC-3) registered agent, whether in the state of
organization (for U.S. entities) or the principal state of registration (for foreign entities). For a sole proprietorship
or partnership, give the address shown on Federal Motor Carrier Safety Administration Records.

MAILING ADDRESS:

Street & Number or P.O. Box              City                                State                                  Zip

PHYSICAL ADDRESS:

Street & Number or P.O. Box             City                                State                                  Zip

BUSINESS PHONE #:            FAX #: 

EMAIL ADDRESS :

BANK REFERENCE:
                                          Name and phone number of personal banker

Current and Past MC Numbers that any Principals or
Officers ever have been affiliated:

                                                          (Write "NONE" if none)
 
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 ABOUT YOUR OPERATION  (OPTIONAL FOR CONTINGENT CARGO QUOTE)
 
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COMMODITIES BROKERED:
 

SO, IN OTHER WORDS, I AM BROKERING...(check all that apply)

DRY GOODS REFRIGERATED GOODS FLATBED FREIGHT TANKER PRODUCTS
HOUSEHOLD GOODS INTERMODAL CONTAINERS
 

 IF REFRIGERATED GOODS, WHAT PERCENTAGE OF TOTAL SHIPMENT?  %

ARE ANY OF THE COMMODITIES THAT YOU BROKER REQUIRED TO HAVE A PLACARD?
(hazardous waste) 

       MORE ABOUT YOUR OPERATION
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CARGO LIMIT YOUR BROKERAGE REQUIRES OF TRUCKER (INSURED WILL BE
REQUIRED TO MONITOR AND CONFIRM THAT THE REQUESTED LIMIT IS IN FORCE FOR ALL
SHIPMENTS AND CONVEYANCES TRANSPORTED BY TRUCKERS THAT THIS INSURANCE WOULD BE CONTINGENT)

DO YOU SPECIALIZE IN ANY ONE TYPE OF MERCHANDISE?  
IF YES, DESCRIBE TYPE:

DO YOU PRIMARILY USE A PARTICULAR CARRIER?
IF YES, GIVE NAME OF CARRIER:

DO YOU OBTAIN CERTIFICATES OF INSURANCE FROM AUTHORIZED CARRIERS? 

IS THE LIMIT IF LIABILITY SHOWN ON THE MOTOR CARRIERS CERTIFICATE OF INSURANCE
ALWAYS
EQUAL TO OR GREATER THAN THE SHIPMENT ASSIGNED TO THAT CARRIER?


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                                                              MORE ABOUT YOUR FREIGHT
_____________________________________________________________________________

DO YOU ARRANGE SHIPMENTS FOR THE FOLLOWING?
 IF YES, WHAT PERCENTAGE OF TOTAL REVENUE?

AUTOS:       
   %                                      BOATS:     %
FURS:          
   %                                  JEWELRY:   
LIQUOR:     
   %                             MACHINERY:   
PRODUCE:  
   %               PHARMACEUTICALS:    %
SEAFOOD:  
   %                      SWINGING BEEF:   
                      TOBACCO PRODUCTS:
  
ELECTRONICS(TV'S,VCR'S,STEREOS, ECT.):
  %  EXPLOSIVES:   %

ARE YOU A MEMBER OF ANY PROFESSIONAL ORGANIZATION?
IF YES, LIST ORGANIZATION(S):

WHAT IS YOUR PRIMARY GEOGRAPHIC TERRITORY (STATES)?

ARE YOU RESPONSIBLE FOR ANY PACKING, LOADING OR UNLOADING?
                                                

  PERSONAL INFORMATION  (REQUIRED)
 
__________________________________________________________________________

Name of Responsible Principal and/or Director:


HOME ADDRESS:

Street & Number or P.O. Box         City                                State                                  Zip

HOME PHONE:  SS#: DATE OF BIRTH:

 

THE ABOVE STATEMENTS ARE TRUE AND ACCURATE TO THE BEST OF MY INFORMATION AND BELIEF.
IN THE EVENT WE HAVE SELECTED PLAN #3 OR #4 ABOVE,
I HEREBY AUTHORIZE A PERSONAL CREDIT INQUIRY.                         I ACCEPT


NAME OF PRINCIPAL:
TITLE:   DATE:


                                               
               



                                                              BONDING AGENT:   MONIKA HANCOCK 1-800-977-9883 EXT 103
               FOR AUTHORITY OR INSURANCE INQUIRY CALL:    JOSH HANCOCK  1-800-977-9884

 

RESPONSE TIME                                     

                UNDER MOST NORMAL CIRCUMSTANCES, QUOTE ARE TURNED AROUND IN 24-28 HOURS.
             ONCE YOUR QUOTE HAS BEEN RECEIVED, WE WILL ATTEMPT TO CONTACT YOU VIA PHONE,
             FAX, AND/OR EMAIL.

IF YOU DO NOT HAVE YOUR BOC-3 PROCESS AGENT FILING YET, GET IT
HERE

IF YOU DO NOT HAVE YOUR MC#, GET IT
HERE

Contact Information

IF YOU HAVE ANY QUESTIONS, OR WOULD LIKE TO DISCUSS BECOMING A FREIGHT  FORWARDER,
 FEEL FREE TO CALL US AT:

1-800-977-9885