Rate Request Form

Complete the form below to request a rate quote for your load. All information is required in order to provide you with a valid quote. If you have questions about items included on this form, please contact our office for assistance.

**** Please Print and Fax this form to (409)579-2626****
Or Email a copy of it to rates@powelltrucking.com 
CONTACT INFORMATION:
Name:     _________________________________    _________________________________   				    First Name                                                                                              Last Name
Company Name:     _________________________________
Billing Address:     _________________________________
                                                  Street Address or PO Box Number
                               ________________________	__________	____________   
                                                 City                                                                              State                               Zip Code 

Phone:     _________________________________    Fax:          _________________________________
                    xxx-xxx-xxxx                                                                                 xxx-xxx-xxxx
Email:     _________________________________     Confirm Email:  _________________________________

LOAD INFORMATION:
Origin:     _________________________________      Destination:     _________________________________
Load Date:           _________________    _________________    _________________
                                              Month			           Date			             Year 

Delivery Date:     _________________    _________________    _________________
                                              Month			          Date			             Year 
Number of Pieces:     _________________________________
Commodity:  _____________________________    Value of Commodity:  _____________________________
Dimensions of Load: :     ______________    ______________	______________    ______________
                                              	       Length			 Width		                   Height                                        Weight                   

Trailer Type Request: (circle one)   53’ Van    Flat    Step Deck    RGN/Double Drop    Unknown    Multi Axle
  
Load Comments:

_____________________________________________________________________________________
 
_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

List any other service that you would like figured into this rate:

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Rates provided by Powell Trucking, Inc. are for quote purposes only and do not constitute a contract for services. Please follow instructions received with your quote to continue the booking process. Your quote will be processed as quickly as possible, but please allow 24 hours for a reply. If you need immediate assistance, please call the business office at (409)579-2121 
Your information will not be shared with any third parties nor will it be used for purposes other than providing you with a quote for this request and future business contact by Powell Trucking, Inc. By submission of this request, you agree to receive future information about services provided by Powell Trucking, Inc. but may at any time request to be removed from our mailing list by contacting the business office.

Powell Trucking, Inc. Rate Request Form; Page 2