Patriot Logistics

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Patriot Logistics, Inc. Agent Pre-Qualification Form

Please fill this form out as complete as possible. All information disclosed is deemed confidential and will not be released or used other than to contact you in regard to this submittal.

Fields marked with * are required.

Company Name: Job Title:
Last Name: First Name: Middle:
*Address:
City: State: *Zip Code:
Phone: Cell: Fax:
*Email: Birthdate:
(Only required if you are a Sole Proprietorship.)

What type of company are you? SSN or EIN
Do you have experience in the transportation industry? Yes No How many years?
*Please explain your current business:
*Are you currently an agent for another company? Yes No
*Do you broker your freight? Yes No If yes, what percentage?
Are you a fleet owner? Yes No Number of trucks: *Number of trailers:
*How many employees do you currently employ?
*Do you have an in-house dispatch management solution? Yes No
Please list equipment year, make, and model of each piece of your equipment:
*Do you have your own operating authority? Yes No
Are you looking for short or long-term financing? Yes No
If yes, please explain:
*Are you interested in outsourcing your administrational, financial, and regulatory compliance needs? Yes No
If yes, please explain:
*Choose the service(s) you are most interested in representing? (Select multiple items by holding down the shift or control key.)
If other, please explain:
Do you know any agents that are currently with the Patriot Logistics network? Yes No

*How did you hear about this business opportunity?

Please read and sign (type) below:

�As part of its pre-qualification process, Patriot Logistics will obtain an investigative consumer report on you. The report may include information regarding your character, general reputation, personal characteristics, and mode of living. Patriot Logistics may use the investigative consumer report in whole or in part for the evaluation of the proposed business relationship, including acting on your pre-qualification. When you click the 'submit application' button below, you authorize Patriot Logistics to obtain an investigative consumer report and acknowledge your understanding that Patriot Logistics may use the report for pre-qualification purposes. You may request that Patriot Logistics completely and accurately disclose to you the nature and scope of the investigation requested. You may also request a written summary of your rights under the Fair Credit Reporting Act. Such request must be made in writing to the Agent Services Division of Patriot Logistics within a reasonable time after you submit this authorization for permission to obtain an investigative consumer report.�

Type your legal name here as you usually sign it, intending this to be your electronic signature.

*Please sign (type) here: *Signing Date:

All information is deemed confidential. It will not be shared with outside parties except within the Patriot Logistics network.