[DATE] Bill of Lading – Short Form – Not Negotiable Page 1 of

Ship From Bill of Lading Number:

Name:
Address
City,/Province
Postal Code: Bar Code Space
SID No.:
Ship To Carrier Name:
Name: Trailer number:
Address: Serial number(s):
City,Province
Postal Code:
CID No.:
Third Party Freight Charges Bill to: SPAC:
Name: Pro Number:
Address:
City,/Province Bar Code Space
Postal Code:
Special Instructions: Freight Charge Terms:
rd
Prepaid: Collect: 3 Party:
Master bill of lading with attached underlying bills
of lading.
Customer Order Information
Customer Order No. No. Packages Weight Pallet/ Additional Shipper
Slip(circl Information
e one)
Y N
Y N
Y N
Grand Total
Carrier Information
Handling Package LTL Only
Unit
Qty Type Qty T Weight HM(X) Goods Description NMFC Class
y Goods requiring special or additional care No.
p or attention in handling or packing must
e be so marked and packaged as to ensure
safe shipping with ordinary care.
Where the rate is dependent on value, shippers are COD Amount: R______________________
required to state specifically in writing the agreed or Free terms: Collect _, Prepaid _, Customer check
declared value of the property as follows: “The agreed acceptable _
or declared value of the property is specifically stated
by the shipper to be not exceeding ______________
per ___________________.
Note: Liability limitation for loss or damage in this shipment may be applicable.
Received, subject to individually determined The carrier shall not make delivery of this shipment
rates or contracts that have been agreed upon in without full payment.
writing between the carrier and shipper, if
applicable, otherwise to the rates, classifications
and rules that have been established by the
carrier and are available to the shipper, on Shipper
request, and to all applicable state and national Signature_________________________________________
regulations. ___
Shipper Signature/Date Trailer Freight Counted: Carrier Signature/Pickup Date
This is to certify that the above- Loaded: _ By shipper Carrier acknowledges receipt of
named materials are properly _ By _ By driver/pallets said to packages and required placards.
classified, packaged, marked and shipper contain Carrier certifies emergency
labelled, and are in proper _ By driver _ By driver/pieces response information was made
condition for shipping according available and/or carrier has the
to the applicable regulations of the DOT emergency response
DOT. guidebook or equivalent
documentation in the vehicle.
Property described above is
received in good order, except
as noted.

Signature Signature
Date Date