Agent Registration

Agency Application Form

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AGENT INFORMATION

Legal Name:

D/B/A :

User Name:

Password:

Login Type:

Hauler Name:

Hauler Code:

Physical Address_Line 1:

Physical Address_Line 2:

County:

City:

State:

Country:

Zip(5 or 9 digits):

Mailing Address:

Same As Physical Address

Mailing Address_Line 1:

Mailing Address_Line 2:

County:

City:

State:

ALABAMA

ALASKA

ARIZONA

ARKANSAS

CALIFORNIA

COLORADO

CONNECTICUT

DELAWARE

DISTRICT OF COLUMBIA

FLORIDA

GEORGIA

IDAHO

ILLINOIS

INDIANA

IOWA

KANSAS

KENTUCKY

LOUISIANA

MAINE

MARYLAND

MASSACHUSETTS

MICHIGAN

MINNESOTA

MISSISSIPPI

MISSOURI

MONTANA

NEBRASKA

NEVADA

NEW HAMPSHIRE

NEW JERSEY

NEW MEXICO

NEW YORK

NORTH CAROLINA

NORTH DAKOTA

NS ADAK, AD

OHIO

OKLAHOMA

OREGON

PENNSYLVANIA

RHODE ISLAND

SOUTH CAROLINA

SOUTH DAKOTA

TENNESSEE

TEXAS

UTAH

VERMONT

VIRGINIA

WASHINGTON

WEST VIRGINIA

WISCONSIN

WYOMING

Country:

Zip(5 or 9 digits):

Phone 1:

Phone 1 Type:

Example-(###-###-####)

Phone 2:

Phone 2 Type:

Example-(###-###-####)

Fax:

Example-(###-###-####)

Federal ID #:

E-Mail Address:

Military Approved 1:

Installations Represented:

From Operation Hours:

To Operation Hours:

After Hours Contact:

Contact Phone:

Contact Phone Type:

Example-(###-###-####)

Military Approved 2:

Warehouse Capacity SF:

Type Storage:

Type Construction:

Name / Address of closest certified scale:

Loading Dock:

Employee Labor:

Contract Labor:

Qual Date:

HAULING INFORMATION

Do you have the capacity to self-haul?

Number of Tractors:

Number of Straight Trucks:

Number of Trailers:

Number of Pack Vans:

Do you haul under your own authority?

ICC #:

If NO, whose authority do you haul under?

ICC #:

Number of Drivers?

Long Haul:

Short Haul:

Do you want to receive our available tonnage list?

Can you perform containerized / lift van service?

PAST AFFILIATIONS

List Below carrier affiliations:

(1) Name:

Address:

From Date:

To Date:

Reason for discontinuing:

(2) Name:

Address:

From Date:

To Date:

Reason for discontinuing:

PRESENT AFFILIATIONS

List below all present carrier affiliations (Including Military)

First Name:

Address:

First Name:

Address:

First Name:

Address:

CERTIFICATION

By clicking the submit button below, I certify that I am an Officer or Owner of the above described Company, certify that the foregoing information is true and correct to the best of my knowledge, and has been taken from the books, records, and files of said company. is true and correct to the best of my knowledge, and has been taken from the books, records, and files of said company.

Covan World-Wide Moving, Inc, /Coleman America Moving Services, Inc, is committed to equal opportunity in vendor selection, employement and services and does not discriminate on the basis of race, color, religion, national origin, sex, age, disability, or citizenship or veteran status as provided by under applicable regultion and by law. We expect all sub-contractors and vendors to adhere to all state and federal laws and/or other regulations relating to equal employement opportunity, affirmative action and those prohibiting discrimination.

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