Carrier Intake Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Carrier Intake Form

Please fill out the form below, providing all pertinent information regarding yourself and your company. One of our specialists will contact you within 1-2 business days to begin the enrollment process.

If you have any questions or concerns, please contact one of our specialist at:

Email: info@willowldservicesllc.com Phone: (803) 386-8210 Toll Free: (888) 851-6283

APPLICANT

Are you a NEW or EXISTING client? *

New

Existing

Applicant Name *

Applicant Address *

Applicant Email *

Applicant Phone *

Are you an OWNER OPERATOR or FLEET OWNER? *

Yes

Are you currently working with another dispatch agency? *

Yes

Self-Dispatch

AUTHORITY

Does your company currently have an active AUTHORITY? *

Yes

Has your AUTHORITY ever been REVOKED? *

Yes

DOT Number *

MC Number *

Is your AUTHORITY less than 90 days old? *

Yes

Not Applicable

COMPANY

Business Name *

Business Address *

Business Email *

Business Phone *

Does your company currently possess the following: *

Hazmat

SCAC Code

Tanker

TWIC Card

None Of The Above

Required

EQUIPMENT

Number Of Trucks *

Truck/s Year/Make/Model/VIN *

Number Of Trailers *

Trailer Type/s: *

Dry Van

Flatbed

Power Only

Refrigerated

Specialty

Other:

Required

Trailer Year/Make/Model/VIN *

Number Of Axles *

Trailer Dimensions *

Trailer Specifics *

Doors, Lift-Gate, E-Tracks, etc...

Maximum WEIGHT you're willing to haul? *

Please list all ACCESSORIES below: *

ROUTES

Available Start Date *

YYYY

Requested $ Per Mile *

Would you like to run LOCAL, OTR, or REGIONAL? *

Local

OTR

Regional

Maximum number of weeks you're willing to RUN in a 30 day period?

Are you willing to RUN all 48 STATES? *

Yes

Which STATES would you like to RUN? *

Which STATES would you like to AVOID? *

Does your company offer CROSS-BORDER services? If YES, where? *

What COMMODITIES would you like to HAUL? *

What COMMODITIES would you like to AVOID? *

ACCIDENTS & INSPECTIONS

Within the last 2 years, has your company had any ACCIDENTS? If yes, WHEN? Briefly explain what happened and any repercussions. *

Has your company had any INSPECTIONS? If YES, when was the most recent? *

DRIVERS

We require a copy of the carrier's commercial drivers license for our records.

Number Of Drivers *

Driver #1 Name *

Driver #1 Email *

Driver #1 Phone *

Driver #2 Name

Driver #2 Email

Driver #2 Phone

Driver #3 Name

Driver #3 Email

Driver #3 Phone

Do you have any questions or concerns?

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Forms