Carrier Form

Carrier Profile

SCAC Code

MC#

MX#

DOT#

Federal Tax ID#

Carrier Name

DBA

Physical Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Website

Owner/President/Principal

Dispatch Contact

Dispatch Contact Phone

Dispatch Email

Dispatch Fax

Accounting Contact

Accounting Contact Phone

Accounting Email

Accounting Fax

After Hours Phone Number

Are you Smart Way Certified?

Yes

No

Insurance Agent Name

Insurance Agent Phone

Number of Tractors

Number of Trailers

Straight Truck Qty

Dry Van Qty

Reefer Qty

Flatbed Qty

Lowboy Qty

Do you have HAZ MAT Certification?

Yes

No

Geographic Service Area

**This information will be used to help us determine future opportunities that may exists based on the services your company provides.

Is your account receivables department is different than your physical address?

Yes

No

Receivable / Factoring Company

Receivable / Factoring Company Name

Receivable / Factoring Company Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Workman's Compensation Certificate Of Election

Certification

This is to certify that the firm named below has elected to not cover its owners, partners or officers under the workers’ compensation laws of the State of:

The firm named below certifies that it has no employees. The firm named below certifies that it uses no independent contractors. Based upon the election not to cover owners, partners or officers, the fact there are no other employees and that no independent contractors are used, a workers’ compensation policy is not purchased.

Agreement

The firm named below promises, in consideration for work received from Client, that if the owners, partners or officers choose to change their election, if any employee is hired or if any independent contractor is used, then a certificate of insurance evidencing workers’ compensation coverage will be furnished prior to the commencement of any work.

Period

The period of this agreement is

to

Carrier

Carrier Name

MC Number

By

Title

Signature

Date

Carrier Payment

Dear Carrier Partner,

Upland Logistics, Inc currently offers a variety of quick payment options, available for a minimal discount.

Please take a moment to complete our Quick Payment Options Agreement, and we will provide payment remitted in two to 14 business days.

To be eligible for Quick Pay, we must receive the following:

A completed Quick Pay agreement form for each invoice submitted.
Your invoice for the contracted amount.
Non‐exception delivery documents signed by the consignee and driver.

*** Please do not submit the Quick Pay form until you have all the required documents ***

*** Required paperwork must be submitted by email to Upland Logistics, Inc by 11:00AM EST to be processed for that day. ***

*** Quick Pay via check is processed and paid Monday‐Friday only, excluding holidays. ***

Please contact Upland Logistics, Inc for more information. Billing@upland-logistics.com

Quick Payment Options Agreement

This form represents an agreement between Upland Logistics, Inc and

to pay the below referenced invoice according to the terms as selected on this form.

By submitting this form, the undersigned acknowledges that this invoice has not been factored or sold to another party.

Quick Payment Options:

2 Business Days via ACH (direct deposit to account) with a 3% discount upon receipt of invoice, rate confirmation, signed bills of lading and/or proof of delivery containing no exceptions.

14 Day Payment – PAID VIA CHECK MAILED 14 DAYS AFTER RECEIPT OF REQUIRED PAPERWORK – with a 1.5% discount upon receipt of invoice, rate confirmation, signed bills of lading and/or proof of delivery containing no exceptions.

30 Day Payment – PAID VIA CHECK MAILED 30 DAYS AFTER RECEIPT OF REQUIRED PAPERWORK – no fee

Upland Logistics, Inc will honor your quick pay for all invoices submitted in good standing until written notice to cancel this agreement is receive by either party. This agreement will become an addendum to the “Broker Carrier” contract agreed to by the carrier and Upland Logistics, Inc. Upland Logistics, Inc may at any time make changes to this agreement for the conduct of its business, as it may, in its judgment, deem necessary or desirable. This agreement may be cancelled at any time. Any such amendments or cancellations will be effective after notice of the amendments has been made to the participating parties.

ACH Payment

Someone will contact you shortly, after you submit this form, to collect your bank account information securely.

Please provide the following information:

Company Name

Company Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Company Phone

MC #

Authorized Signature

Date

W-9

Please download and fill out the highlighted areas on this form.

Or email W-9 form to sales@upland-logistics.com

Download W-9 Form Here

Upload Completed W-9

Drop files here or

Max. file size: 32 MB.

Model Motor Carrier / Broker Agreement

Please download and fill out this form.

Download Model Motor Carrier / Broker Agreement Here

Upload Completed Model Motor Carrier / Broker Agreement

Drop files here or

Max. file size: 32 MB.

Your Email Address*

Required to submit this form.

Name

This field is for validation purposes and should be left unchanged.

Carrier Profile

Receivable / Factoring Company

Workman's Compensation Certificate Of Election

Certification

Agreement

Period

Carrier

Carrier Payment

Dear Carrier Partner,

Quick Payment Options Agreement

ACH Payment

Please provide the following information:

W-9

Please download and fill out the highlighted areas on this form.

Model Motor Carrier / Broker Agreement

Please download and fill out this form.

Avery Scott

Mario Niebrzydowski