Date

Bill of Lading – Short Form – Not Negotiable

Page 1 of 1

Ship From

Bill of Lading Number:

SID No.:

Bar Code Space

Ship To

Carrier Name:

CID No.:

Trailer number:

Serial number(s):

Third Party Freight Charges Bill to

SCAC:

Pro Number:

Bar Code Space

Special Instructions:

Freight Charge Terms (Freight charges are prepaid unless marked otherwise):

Prepaid q  Collect q  3rd Party q

q Master bill of lading with attached underlying bills of lading.

Customer Order Information

Customer Order No.

# of Packages

Weight

Pallet/Slip
(circle one)

Additional Shipper Information

Y

N

Y

N

Y

N

Y

N

Grand Total

Carrier Information

Handling Unit

Package

LTL Only

Qty

Type

Qty

Type

Weight

HM (X)

Commodity Description

Commodities requiring special or additional care or attention in handling or stowing must be so marked and packaged as to ensure safe transportation with ordinary care. See Section 2(e) of NMFC item 360

NMFC No.

Class

Where the rate is dependent on value, shippers are required to state specifically in writing the agreed or declared value of the property as follows: “The agreed or declared value of the property is specifically stated by the shipper to be not exceeding _______________ per _______________.

COD Amount: $ _______________________________________________

Fee terms: Collect q     Prepaid q     Customer check acceptable q

Note: Liability limitation for loss or damage in this shipment may be applicable. See 49 USC § 14706(c)(1)(A) and (B).

Received, subject to individually determined rates or contracts that have been agreed upon in writing between the carrier and shipper, if applicable, otherwise to the rates, classifications, and rules that have been established by the carrier and are available to the shipper, on request, and to all applicable state and federal regulations.

The carrier shall not make delivery of this shipment without payment of charges and all other lawful fees.

Shipper Signature  __________________________________________________________

Shipper Signature/Date

___________________________________________

This is to certify that the above named materials are properly classified, packaged, marked, and labeled, and are in proper condition for transportation according to the applicable regulations of the DOT.

Trailer Loaded:

q By shipper

q By driver

Freight Counted:

q By shipper

q By driver/pallets said to contain

q By driver/pieces

Carrier Signature/Pickup Date

__________________________________________

Carrier acknowledges receipt of packages and required placards. Carrier certifies emergency response information was made available and/or carrier has the DOT emergency response guidebook or equivalent documentation in the vehicle. Property described above is received in good order, except as noted.