Reference:


 
   


CONTACT INFORMATION

 
  LEGAL BUSINESS NAME:  
  Your Name:  
  Company:  
  Account?  
  Area/Phone:       Ext:  
  E-mail:  
 

 
   


PICK-UP LOCATION

 
  WHERE FROM?    
  Contact:  
  Company:  
  Area/Phone:       Ext:  
  Address:  
     
  City/State:       Zip:  
  Province:  
  Country:  
   


CUSTOMS INFORMATION

 
  Port of Entry:  
  Mexican Broker:  
  Area/Phone:       Ext:  
  U.S. Broker/
Forwarder:
 
  Area/Phone:       Ext:  
  Comments/
Additional
Information:

 
   


SHIPMENT DESTINATION

 
  WHERE TO?    
  Contact:  
  Company:  
  Area/Phone:       Ext:  
  Address:  
     
  City/State:       Zip:  
  Province:  
  Country:  
 

 
   


SHIPMENT DESCRIPTION

 
  DESCRIPTION    
  P/U Date:      Qty. Shipments:  
  P/U by:        a.m.p.m.  
  Pieces: cartons crates drums pallets reels
rolls other: Total pieces:
 
  Description:  
     
  Weight:        Pounds Kilos  
  Volume:  Cubic:Feet Meters  
  In-bond? Yes No          Hazardous? Yes No  
  Terms: Pre-paid  Collect Third Party  Account  
  Third Party:  
  Account:  
 

 
 

 
 
Please note that the form will only return properly
when the name and email lines have entries.

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