BacklotCars Carrier Agreement
Company Name
*
Contact Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Payment Email
*
example@example.com
Payment Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
DOT Number
*
ICC Number MC
*
Tax ID/EIN Number
*
Insurance Agent
*
Insurance Phone Number
*
Please upload the following documents:
Copy of W9
*
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Cancel
of
Copy of MC Authority
*
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Cancel
of
Certificate of Insurance
*
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Must list BacklotCars as a certificate holder
Cancel
of
Signature Here:
*
Save
Submit agreement
Should be Empty: