Shipper Name *			PICKUP INFORMATION
Shipper Address *			Pickup Date: Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec   Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31   Year 2009 2010 2011 2012
City *			Pickup Time : Ready: Hour Midnight 12 1 2 3 4 5 6 7 8 9 10 11 Noon   :00 :15 :20 :25 :30 :35 :40 :45 :50 :55   AM/PM - - AM PM
State * Select AK AL AR AS AZ CA CO CT DC DE FL FM GA GU HI IA ID IL IN KS KY LA MA MD ME MH MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN WY TX UT VA VT WI WA WV	Zip *	Phone with AC * Ex	Close Hour Midnight 12 1 2 3 4 5 6 7 8 9 10 11 Noon   :00 :15 :20 :25 :30 :35 :40 :45 :50 :55   AM/PM - - AM PM
Shipper's Email *

1st Destination Zip:			Shipment Handling Instructions:
Pck: - - - Bundle Bag Bucket Bale Barrel Basket Box Can Coil Crate Case Carton Drum Each Envelope Gaylord Hopper Kit Loose Piece Package Pail Pallet Reel Roll Rack Skid Tote bin Tank Vpk Unit	Pieces:	Weight:

2nd Destination Zip:			Shipment Handling Instructions:
Pck: - - - Bundle Bag Bucket Bale Barrel Basket Box Can Coil Crate Case Carton Drum Each Envelope Gaylord Hopper Kit Loose Piece Package Pail Pallet Reel Roll Rack Skid Tote bin Tank Vpk Unit	Pieces:	Weight:

3rd Destination Zip:			Shipment Handling Instructions:
Pck: - - - Bundle Bag Bucket Bale Barrel Basket Box Can Coil Crate Case Carton Drum Each Envelope Gaylord Hopper Kit Loose Piece Package Pail Pallet Reel Roll Rack Skid Tote bin Tank Vpk Unit	Pieces:	Weight:

4th Destination Zip:			Shipment Handling Instructions:
Pck: - - - Bundle Bag Bucket Bale Barrel Basket Box Can Coil Crate Case Carton Drum Each Envelope Gaylord Hopper Kit Loose Piece Package Pail Pallet Reel Roll Rack Skid Tote bin Tank Vpk Unit	Pieces:	Weight: