DATE Customer Email    
CONSIGNEE DETAILS
CONSIGNEE NAME: CONSIGNEE PHONE
ZIP CODE ADDRESS
CITY STATE
SHIPPER DETAILS
SHIPPER NAME: SHIPPERS PHONE
SHIPPERS NO. ADDRESS
ZIP CODE CITY
STATE HAZ-MAT EMERGENCY PHONE NO.
SHIPPER READY TIME SHIPPER CLOSE TIME
FREIGHT CHARGES ARE PREPAID unless marked collect CHECK BOX IF COLLECT........
BILL TO: THIRD PARTY DETAILS
BILL TO: THIRD PARTY ADDRESS
ZIP CODE CITY
STATE
QUOTE NO. PURCHASE ORDER NO.
COD
Total Amount $ Check Appropriate Box  
COD fee to be paid by:
On a Collect On Delivery shipment(s), the letters “COD” must appear before consignee’s name or as otherwise provided in Item 430, Sec. 1.
REMIT COD TO: ADDRESS
ZIP CODE CITY
STATE
Pallets Pieces PKG. TYPE HM = X DESCRIPTION OF ARTICLES, SPECIAL MARKS, AND EXCEPTIONS WEIGHT (LB) SUBJ. TO CORR CLASS NMFC ITEM NO
Note 1 – Where the rate is dependent on value, shippers are required to state specifically in writing the agreed or declared value of the property. The agreed or declared value of the property is hereby specifically stated by the shipper to be not exceeding:
$ _

per
Note 2 – Liability limitation for loss or damage on this shipment may be applicable. See 49 U.C.S. 14706(c)(1)(A) and (B). Note 3 – Commodities requiring special or additional care or attention in handling or stowing must be so marked and packaged as to ensure safe transportation with ordinary care. See Sec. 2(e) of NMFC Item 360.
SPECIAL INSTRUCTIONS

Subject to Section 7 of the conditions, if this shipment is to be delivered to the consignee without recourse on the consignor, the consignor shall sign the following statement. The carrier shall not make delivery of this shipment without payment of freight and all other charges.

(Signature of Consignor)
RECEIVED, subject to individually determined rates or contracts that have been agreed upon in writing between the carrier and shipper, if applicable, otherwise to the rates, classifications and rules that have been established by the carrier and are available to the shipper, on request; the property describe above in apparent good order, except as noted (contents and condition of contents of packages unknown), marked consigned, and is destined as indicated above which said carrier (the word carrier being understood throughout this contract as meaning any person or corporation in possession of the property under the contract) agrees to carry it to its usual place of delivery at said destination, and as to each party at any time interested in all or any of said property, that every service to be performed hereunder shall be subject to all the terms and conditions the Uniform Bill of Lading set forth in the National Motor Freight Classification 100 and successive issues.
The shipper certifies that the above-named materials are properly classified, described, packaged, marked and labeled, and are in proper condition for transportation according to the applicable regulations of the Department of Transportation.
SHIPPER CARRIER ACI Motor Freight, Inc.
PER PER