Ajax Transport Carrier Contract Form

To be set up as a Carrier to move freight for us please please fill out the information below. After you fill out this form click the submit button. We will email or fax you our contract. Please review it, sign it and fax it back along with your authority, W-9 and insurance and any other information you would like us tohave. Fax back to: 901-527-7403. For help please call us at 901-527-7400

Carrier Name

Mailing Address

SuiteCity State Zip

***Note***Checks will only be mailed to the above address. Unless otherwise stated below.

Make checks payable to:

MC # Federal ID #

Contact Information

Please enter telephone numbers as 123-456-6798.

.Telephone #Toll Free FaxEmergency

Dispatcher Dispatch EmailExt

Operations ManagerOperations ManagerEmailExt

Safety Manager Safety Manager EmailExt

Insurance Information

Auto Liability AgentInsurance Agent Tel.# Fax #Email

Gen. Liability AgentInsurance Agent Tel.# Fax #Email

Cargo Ins AgentInsurance Agent Tel.# Fax #Email

Traffic Lanes and Equipment type

Select as many different types of equipment as you have. Hazmat Permit? Liquor Permit?

Select States you need loads out of 1

Person you booked load with:

Would you like our contract emailed or faxed to you?

Please type the email address you would like us to email the contract to.

Once your information is submitted we will email our contract to the email address you provided above.