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 W9Fax to:513-539-8437 attn:Mel