Issued in accordance with the regulations made under the truck transportation act.

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Information
	Carrier's Ref No.:	Vehicle No.:	Cosignor's Ref. No.:
Point of Origin
	Date:
	Address:
	City:
	State/Province:	Zip/Postal Code:
Consignor
	Name:
	Address:
	City:
	State/Province:	Zip/Postal Code:
Consignee Information
	Name:
	Address:
	City:
	State/Province:	Zip/Postal Code:
Destination
	Address:
	Route:
	City:
	State/Province:	Zip/Postal Code:
Shipment Information
	# of Pieces / Quanitity Description of Goods / Special Marks Dangerous Goods Weight Class Prim. & SubsId PIN/UN Number Packing Group Lbs. Kilos.
	Placecard Number Type 24 Hour Emergency Number
	Special Agreement between cosigner and carrier (if any):
Frieght Charges
	Prepaid       Collect
C.O.D Shipments
	Prepaid	Collect
	Amount:	$
	Collect Charge:	$
	GST:	$
	Totals:	$
	Inbound:	$
	Beyond:	$
	Others:	$
		$
	Totals:	$
Other
	Declared Value: MAXIMUM LIABILITY SHALL NOT EXCEED $4.41 PER KILOGRAM COMPUTED ON THE TOTAL WEIGHT OF THE SHIPMENT UNLESS DECLARED VALUATION STATES OTHERWISE.
	$
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