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Customer Service Rate Quote Request Form

Contact Information

*Required fields

*First Name:
*Last Name:
*Company Name:
State: Zip Code:
*Phone: ext.
Fax: ext.
*Confirm email:
*Would you like us to: e-mail    Fax    Phone     your rate quote back to you?
Shipping Information
*Origin City:
*Origin State: *Origin Zip Code:
*Destination City:
*Destination State: *Destination Zip Code:
Projected Ship Date: Month:   Day:   Year:
Declared Value:
Number of Shipments:   Shipment weight (in pounds):
*Trailer Requirements: Trailer Size in Feet:
Material Class:
Special Requirements or Instructions:
*Commodity Description:
How is the shipment packaged? Palletized         Loose Packages      Slip Sheet
Loading Method? Driver Load       Shipper Load
Unloading Method? Driver Unload    Destination Unload
Hazardous Materials? Yes   No
Additional Serivices Requested:
Submit freight BILL to: Additional paperwork required at billing    Shipper   Receiver   Third Party

GEMM Enterprises, Inc.   Suite 2006 Kinvara Drive McKnight East Plaza One   Pittsburgh, PA 15237
1.800.486.4366   412.367.6114   info@gemment.com