Agents Form


Terminal Data Sheet

Terminal Number:(Assigned by Corp. Office)
Date:
Terminal Information:
Agent:
Terminal Name:
Physical Street Address:
City/State/Zip:
Phone:
U.S.Watts:
Fax:
Cell:
Email :
Dispatcher(If Different From Agent):
Mailing Address:(if Needed)
Name:
Address:
City/State/Zip:
Tax Information for 1099(Fill Out attached W9 form and return with this information)
Name:
Address
City/State/Zip:
Social Security Number:
Federal ID Number:
(Only if reporting under a company name)
Driver on Weekly Pay: Yes:No:
Driver on Terminal Pay: Yes:No
Which Office to handle settlements:Cincinnati          
This form must be faxed to the Safety Department in Middletown along with W9
Fax to:513-539-8437 attn:Mel