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Company Name
Your Name
Phone
xxx-xxx-xxxx
Extension #
Email
State
Zip Code
Shipment Information
Origin City
Origin State
IA
IL
IN
KS
KY
MO
NE
OH
OK
Origin Zip Code
Destination City
Destination State
IA
IL
IN
KS
KY
MO
NE
OH
OK
Destination Zip Code
Total Pieces
Total Weight
(Pounds)
Dimenions
Accessorial Charges
(Check all that apply)
Liftgate Delivery
Liftgate Pickup
Pallet Jack
2 Person Pickup/Delivery
Residential Delivery
Residential Pickup
Inside Delivery
Inside Pickup
Military/Government Facility/School
Authorize Wait Time
Special Pickup/Delivery (limited hours or special availabilty
No Convention Center pickups or deliveries. Contact your local cartage agent!
C.O.D. $
Excess Value $
C.O.D. $
Contact Midwest Express Co. if over $50,000.00
Yes
NO
Hazardous Material
Yes
NO
Hazmat Class
Midwest Express will NOT Accept the Following Hazmat:
Division 1.1 - 1.2 - 1.3 - 1.4 - 1.5 - 1.6
Division 2.3, Hazard Zone A
Division 6.1, PG1, Hazard Zone A
Highway Route Controlled quantities of a Class 7 as defined in 49 CFR 173.403
Note / Comments