Boat Transporter/Driver Profile

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Truckin' A Boat

 Print and Mail or Fax this Form

$150 (US) for 3 full months, pre-paid orders $250. for 6 months, $500. for 1 year.
Master Card / Visa, Company Check by fax. Photo copy your check and fax to
561-451-4243 Made payable toCrown Eagle, Inc.

Amount of: $150 for 3 months: __ $250 for 6 months: __ $500 for 1 year: __

Credit Card information
(Please Note: There is a 5% processing fee for all credit card information)

Card Name: .........Master Card ___ Visa ___

Account #: ________________________________________ Expiration Date ________

Cardholder Name: (print name) ____________________________

Signature:____________________________

Please Note: Your order will be processed by Les Schwartz, Inc. Their name will appear onyour credit card billing statement for yhe amount of this purchase. ($25 fee will be charged for re-processing of charge backs)

Your Name: _______________________________

Address: _____________________________ City: ___________ State: ___ Zip: __________

Business Address: ________________________ City: _____________ State: ___ Zip: __________

Phone: (Home) _____________________ (Business) _____________________

Fax: __________________ E-mail: ___________________ Other: __________________

Company Name: ____________________________________

CDL Class: _____ Endorsement (s): ____________________________________

Please Fax Copies of your U.S.D.O.T. Certificate, Motor Carriers Authority and Insurance.

Truck: Year: ____ Make: ____________ Model: ______ Trailer : Year ___ Make___________

Tractor: Year: _____ Make: ____________ Model: _______ Trailer: Year ____ Make:________

Load Capabilities: Maximum: _______________

Desired Areas of Operation: All 48 states: __ North __ South __ East __ West _

Eastern seaboard: __ Southeast: __ Mid-Atlantic: __ New England __

Midwest __ South Central __ North Central __ Southwest __ Northwest __

Central Mountain __ West Coast __

Additional Information: ___________________________________________________________

________________________________________________________________________________

 

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