POTENTIAL CUSTOMER QUESTIONNAIRE

This form is designed to help us get a rate for you as soon as possible. In order for us to do this, we need you to fill out this Questionnaire COMPLETELY. If it is not filled out completely we cannot possibly get you a rate. All information is necessary to get a competitive rate. If you have any question, or do not have all the needed information, please contact us. Thank you for giving us the opportunity to help you with your transportation needs.

Today's Date

YYYY

Shipper Info

Shipper

Shipper Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Shipper Contact

Shipper Phone

(###)

###

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Origin Info

Origin Contact:

Origin Station

Origin Railroad

Origin Phone

(###)

###

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Receiver Info

Receiver

Receiver Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Receiver Contact

Receiver Phone

(###)

###

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Destination

Destination Station

Destination Railroad

Commodity

STCC No:

Type Of Car

Weight Requirements

Approximate number of cars per year

Shipments would begin on

YYYY

Truck rate (optional)

Rate needed to compete

Routing

Prepaid or Collect

Prepaid

Collect

Inbound or Outbound

Inbound

Outbound

Special Requirements

Does car need to be weighed?

Yes

Do you have rail siding or spur?

Yes

If answered No above, Where do you plan to access rail cars

Person Completing form

Your Company

Phone

(###)

###

####

Fax

(###)

###

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