<% '**************************************************************************** '* This page should be included in every ASP page in the web site. '* If cookies are on we will use them. We will still pass the OrderID '* to every ASP page within the site. Change after "-" in cookie ID below. '**************************************************************************** 'Vinnie Chas If request("OrderID") = "" Then If Request.Cookies("StevensWest") = "" Then RANDOMIZE OrderID = Session.SessionID & INT((99999999999999 - 1 + 1) * RND) Response.Cookies("StevensWest")=OrderID Response.Cookies("StevensWest").Expires=DATEADD("d",1,DATE) & " " & TIME() Response.Cookies("StevensWest").Domain = Request.ServerVariables("SERVER_NAME") Else OrderID = Request.Cookies("StevensWest") End If Else OrderID = request("OrderID") End If %> Stevens West: Shipper Pickup Request Form

Customer Pickup Request
Requester

*Required Field
Name *
 Title
Company Name *
 Branch Location (if any)
Phone Number*
 Email Address *
Quote Number (if any)
  


Time Frame

Ready For Pickup Date * Pickup No Later Than Date * Deliver No Later Than Date*
(mm/dd/yy) (mm/dd/yy) (mm/dd/yy)


Pickup Location (Shipper)

Contact Name
 Company Name *
Street Address *
 City *
State/Province *
 Zip/Postal Code
Contact Phone *
 Country
U.S.CanadaMexico


Delivery Location (Consignee)

Contact Name
 Company Name *
Street Address *
 City *
State/Province *
 Zip/Postal Code
Contact Phone *
 Country
U.S.CanadaMexico



Intermediate Stops

List any stops between origin and destination below - (give as much detail as possible)


Truckload / Less Than Truckload

Dedicated Truckload Less Than Truckload (Partial Shipment)


Weight & Dimensions

Total Weight
(Required for TL or LTL)		 Total Dimensions
(L x W x H) (Required for LTL)		 # of Pieces Hazardous

or xx

If you have the weights and dimensions of individual pieces, list them here.



Service Options

Tarp Covering
Declared value of goods US$
COD or Third Party Billing
Appointment- Loading / Unloading
Expedited Shipment
Driver Wait Time (over 2 hours - origin or dstn)
Other


Special Instructions




Call Toll Free:
1-888-606-5599
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