ProviderLink — Company Intake & Delivery Request

Company Name *

Company name is required.

DBA (if any)

Website

Organization Type *

Please choose an option.

HQ / Billing Address *

Address is required.

Suite / Apt

City *

City is required.

State *

State (2 letters) is required.

Zip *

Zip is required.

DOT #

MC #

DUNS # (optional)

Step 1 of 8

Primary Contact Name *

Required.

Title

Phone *

Required.

Email *

Enter a valid email.

Primary Pickup Location(s) *

At least one pickup location is required.

Delivery Region(s)

Dock/Operating Hours

How did you hear about us?

Site Requirements

Insurance Requirements

Articles of Incorporation (optional upload)

EIN Document (optional upload)

Proof of Authority (optional upload)

SOP / Work Instructions (optional upload)

Vendor Packet / MSA (optional upload)

Other Attachment

Contract Details (if any)

Contract Proofs (PDF or Image) — you can attach multiple files

SLAs & Agreements

Review the , , and .

I have read and agree to the Terms & SLAs. * I am authorized to request services on behalf of my company. *

Authorized Signature (type full name) *

Signature required.

Date *

Required.

Name (as shown on tax return)

Business name / disregarded entity

Address

City, State, ZIP

Taxpayer Identification Number (SSN or EIN)

I certify the TIN is correct and I am not subject to backup withholding.

Signature

Date

Bank Name

Routing Number

Account Number

Account Type

Signature

Date

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