Create - JWLApplication

CARRIER INFORMATION

* Fields are Mandatory

Agreement Date: 06/03/2023

DOT#*

MC#

CA#

Are you a broker or carrier?*

Authorized Person*

Title*

Legal Company Name

DBA

Email*

Physical Address *

State*

City*

Zip Code*

Phone*

Fax

How long have you been in business?

Miles per year?

Cargo Specialties (Select all that apply)

Payment Methods (Select all that apply)

What is your racial or ethnic identification?

Are you a minority owned business?

Are you a female-owned business?

Are you a veteran-owned business?

ADD FACTORING INFO, IF APPLICABLE

Factoring Company Name

Contact Name

Phone

Fax

Physical Address

State

City

Zip Code

ADDITIONAL INFORMATION

Disptach Person Name*

Dispatch Phone*

After-Hours Dispatch Person Name*

After-Hours Dispatch Phone*

SCAC Code

Federal Tax ID*

TWIC Certified?

Hazmat Certified?*

Hazmat Expiration Date

Authorized Signature*

Preferred Lanes

Service Area*

Operating States (Select all that apply)

Vehicle Type

Fleet Size

Trailer Type

Trailer Count

Carrier Registration

CARRIER INFORMATION

ADD FACTORING INFO, IF APPLICABLE

ADDITIONAL INFORMATION

Attach Documents