| New Order |
Change Order |
Cancellation |
| Order
# |
Shipment
Code |
|
Account
# |
GBL
# |
| Customer
Name:
(Last, First, Middle I.) |
Military
Rank |
Origin
City
Address |
Origin
Military Base |
Origin
GBLOC |
Origin
City |
Origin
State |
ZIP
Code |
Origin
Agent:
Code # |
Origin
Phone(s)
and /or contacts |
Destination
St. Address |
Destination
Military Base |
Dest.
GBLOC |
Destination
City |
Destination
State |
ZIP
Code |
Destination
Agent:
Code # |
Dest.
Phone(s) or contacts |
| Packing
Dates |
Load
Spread
or Date |
Delivery
Spread or Date |
| SS#
(if required) |
Hauler
(self-haul) |
Driver
# |
Est. Linehaul
(after discount) |
| Weight |
Discount %
Bottom Line LH |
Total Charges
(COD only) |
| Miles |
Tariff |
Valuation
Type
Full Value Guar.
Dep. Value |
Amt.
$1.25
60 Cents |
| Special Requirements,
Comments: |
| Dated
Faxed: |
Person
Registering @ Your Agency: |