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Thank you for choosing DIVINE HIGHWAY LOGISTICS. Please fill out the following information to the best of your ability. If the question does not apply to you please answer "N/A" in the blank space.

FULL NAME

DATE

COMPANY NAME or DBA

PHONE #

EMAIL ADDRESS

PREFERRED METHOD OF CONTACT

PHONE

EMAIL

MC#

DOT#

WHAT TYPE OF TRAILER(S) DO YOU HAVE (include dimensions)

HOW MANY TRUCKS DO YOU HAVE?

DO YOU HAVE A FACTORING COMPANY?

YES

NO

IF "NO" HOW DO YOU INTEND ON GETTING PAID?

FACTORING COMPANY NAME

FACTORING COMPANY PHONE #

DRIVER'S NAME

PREFERRED GEOGRAPHICAL LANES

SOUTHERN STATES

WEST COAST STATES

MIDWEST STATES

NORTH EAST STATES

SOUTH EAST STATES

ZONES TO "AVOID"

ZONE 0

ZONE 1

ZONE 2

ZONE 3

ZONE 4

ZONE 5

ZONE 6

ZONE 7

ZONE 8

ZONE 9

LIST ANY PREFERRED LANE DETAILS

BREAK EVEN POINT

MAX LOAD CAPACITY

Email Address to receive invoices from DIVINE HIGHWAY LOGISTICS

INSURANCE COMPANY NAME (Copy of Origial Certificate will be requested)

AGENT AND CONTACT INFORMATION

STARTING LOCATION

HOW LONG HAVE YOU HAD YOUR AUTHORITY?

Thanks for submitting!

Divine Highway Logistics will get back with you soon!

DIVINE HIGHWAY LOGISTICS

divinehighwaylogistics@gmail.com

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