Shipper Info Company Address City   State: Select StateALABAMAALASKAARIZONAARKANSASCALIFORNIACOLORADOCONNECTICUTDELAWAREDISTRICT OF COLUMBIAFLORIDAGEORGIAHAWAIIIDAHOILLINOISINDIANAIOWAKANSASKENTUCKYLOUISIANAMAINEMARYLANDMASSACHUSETTSMICHIGANMINNESOTAMISSISSIPPIMISSOURIMONTANANEBRASKANEVADANEW HAMPSHIRENEW JERSEYNEW MEXICONEW YORKNORTH CAROLINANORTH DAKOTAOHIOOKLAHOMAOREGONPENNSYLVANIARHODE ISLANDSOUTH CAROLINASOUTH DAKOTATENNESSEETEXASUTAHVERMONTVIRGINIAWASHINGONTWEST VIRGINIAWISCONSINWYOMING  Zip: Phone: Notes:   Consignee Info: Company Address City  State: Select StateALABAMAALASKAARIZONAARKANSASCALIFORNIACOLORADOCONNECTICUTDELAWAREDISTRICT OF COLUMBIAFLORIDAGEORGIAHAWAIIIDAHOILLINOISINDIANAIOWAKANSASKENTUCKYLOUISIANAMAINEMARYLANDMASSACHUSETTSMICHIGANMINNESOTAMISSISSIPPIMISSOURIMONTANANEBRASKANEVADANEW HAMPSHIRENEW JERSEYNEW MEXICONEW YORKNORTH CAROLINANORTH DAKOTAOHIOOKLAHOMAOREGONPENNSYLVANIARHODE ISLANDSOUTH CAROLINASOUTH DAKOTATENNESSEETEXASUTAHVERMONTVIRGINIAWASHINGONTWEST VIRGINIAWISCONSINWYOMING Zip: Phone: Notes: Payor/Forwarder Info: Company Address City  State: Select StateALABAMAALASKAARIZONAARKANSASCALIFORNIACOLORADOCONNECTICUTDELAWAREDISTRICT OF COLUMBIAFLORIDAGEORGIAHAWAIIIDAHOILLINOISINDIANAIOWAKANSASKENTUCKYLOUISIANAMAINEMARYLANDMASSACHUSETTSMICHIGANMINNESOTAMISSISSIPPIMISSOURIMONTANANEBRASKANEVADANEW HAMPSHIRENEW JERSEYNEW MEXICONEW YORKNORTH CAROLINANORTH DAKOTAOHIOOKLAHOMAOREGONPENNSYLVANIARHODE ISLANDSOUTH CAROLINASOUTH DAKOTATENNESSEETEXASUTAHVERMONTVIRGINIAWASHINGONTWEST VIRGINIAWISCONSINWYOMING Zip: Phone: Notes: Details Pickup Date: Time: Delivery Date Time: Additional Notes Declared Value $ If nothing is stated, carrier’s maximum liability is agreed and understood to be $.50/lb multiplied by the number of pounds for each piece of the shipment which may have been lost, damaged, or destroyed, unless a higher value is declared herein and applicable charges paid herein.  In the event of higher declared value a charge of $.65 per $100 or fraction thereof shall be accessed. Rate Quoted Line Haul: Fuel Surcharge: Stop Charges: Other: Total: Customer Reference # Submitting this form constitutes agreement that this shipment will be governed by the Xpress Direct standard terms and conditions applicable at the time of shipment, and confirmation that the information above is correct.