Agents Form - OHIO TransportOHIO Transport

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

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