Pickup Request Form
»
denotes required form fields
»
First Name:
»
Last Name:
»
Telephone:
»
Email:
»
Shipper:
»
Shipper Address:
»
Shipper City:
»
Shipper State:
Shipper Zip:
»
Shipper Country:
»
Shipper Telephone:
Shipper Fax:
Shipper Hours:
Shipper Ref:
»
Consignee:
»
Consignee Address:
»
Consignee City:
»
Consignee State:
Consignee Zip:
»
Consignee Country:
»
Consignee Telephone:
Consignee Fax:
Consignee Hours:
»
Available Pickup Date:
If your shipment requires a Specific Delivery Date/Time or is time sensitive, indicate below. Leave blank for standard delivery service.
Delivery Date/Time:
If your shipment requires a Special Handling, (lift gate, inside delivery, temperature control, 2-men, etc.) indicate below.
Special Handling:
»
Commodity Being Shipped:
»
Number of Pieces/Skids:
»
Dimensions of Pieces/Skids:
»
Total Weight:
»
PO Number (required):
DO NOT USE THESE CHARACTERS AMPERAND (&) OR PLUS (+)
Special Shipping Requirements:
Support contact:
jonathan@lakesoft.net
All Rights Reserved Jonathan Laub Copyright 2015