Network Supplier Worksheet

Section 1 - Company Information
*Red fonts denotes required fields*
Company Legal Name
DBA
Principal Owner
Address
US DOT Number
MC Number
US DOT Satisfactory Safety Compliance Review
Checked on SaferSys
Facility Manager
Facility Phone
Facility Fax
Operations Manager
Phone Number
Fax Number
Email
Web Site URL

Section 2 - General Information
Primary Service Provided
Primary Type of Product Handled
Geographic Coverage Area
Points Lists by Zip Code
Airports Served
Other Locations

Section 3 - Stability Information
Number of Years in Business
Number of Years Under Same Name
Number of Years at this Location
Any Past Bankruptcies
Type of Ownership

Section 4 - Services Provided
Truck Load YesNo
LTL YesNo
P and D YesNo
Scheduled Services YesNo
On Demand YesNo
Exclusive Use YesNo
Dedicated Route YesNo
Next Day Distribution YesNo
NFQ YesNo
Inside Delivery YesNo
Retail Distribution YesNo
Drayage YesNo
Residential Deliveries YesNo
Other Service Type
Parts or Product Storage and Distribution
Kitting
Pool Distribution
Specialty Labeling
Point of Purchase Display Installations
Other

Section 5 - Facility Information
Hours of Operation
Receiving Hours
Total Square Feet
Number of Dock Doors
Caged Security Area YesNo
Type of Security
Square Foot Available
Warehouse Racking YesNo

Section 6 - Equipment Information
Tractors YesNo
Straight Trucks YesNo
Cars YesNo
Scale YesNo
Trailers YesNo
City Vans YesNo
Capped Pick Ups YesNo
Fork Lift YesNo
RF YesNo
Other Equipment

Section 7 - Electronic Communications
Bar Code Scanning YesNo
GPS Tracking YesNo
Signature Image Capture YesNo
Driver Two Way Data Trans YesNo
Web Based Inventory management Systems
EDI YesNo
XML YesNo
FTP YesNo

Section 8 - Employee Information
Number of Drivers
Company Drivers
Independent Contractors
Warehouse Personnel
Total Personnel
Background Checks prior to Employment YesNo
Drug Testing Check YesNo
MVR Check YesNo
Frequency Performed

Section 9 - Insurance Information
Warehouse Legal Liability
Property
Injury or Death of One Person
Workers Compensation
Automobile Liability Owned Non Owned leased Vehicles
Exemptions
Cargo Liability

Section 10 - Certification Information
ATA YesNo
MCAA YesNo
ECA YesNo
Women or Minority Owned YesNo
US Customer Bonded YesNo
Blood Pathogen YesNo
ISO 9002 YesNo
HAZMAT YesNo
Other Specialty