Date                                           BILL OF LADING – SHORT FORM – NOT NEGOTIABLE                                                                                               Page 1 of 1
SHIP FROM                                                      Bill of Lading Number:
SID No.:
                                             SHIP TO                                                     Carrier Name:
                                                                                                         Trailer number:
                                                                                                         Serial number(s):
                  THIRD PARTY FREIGHT CHARGES BILL TO                                                    SCAC:
                                                                                                         Pro Number:
Special Instructions:                                                                                    Freight Charge Terms (Freight charges are prepaid unless marked otherwise):
                                                                                                         Prepaid  Collect  3rd Party 
                                                                                                          Master bill of lading with attached underlying bills of lading.
                                                                              CUSTOMER ORDER INFORMATION
                                                                                                                         Pallet/Slip
Customer Order No.                                                                # of Packages          Weight                             Additional Shipper Information
                                                                                                                        (circle one)
                                                                                                                         Y          N
                                                                                                                         Y          N
                                                                                                                         Y          N
                                                                                                                         Y          N
Grand Total
                                                                                     CARRIER INFORMATION
Handling Unit                  Package                                                                                                                                                 LTL Only
 Qty         Type          Qty          Type         Weight       HM (X)       Commodity Description                                                                          NMFC No.             Class
                                                                               Commodities requiring special or additional care or attention in handling or stowing must
                                                                               be so marked and packaged as to ensure safe transportation with ordinary care. See
                                                                               Section 2(e) of NMFC item 360
Where the rate is dependent on value, shippers are required to state specifically in writing the agreed or       COD Amount: _______________________________________________
declared value of the property as follows: “The agreed or declared value of the property is specifically
stated by the shipper to be not exceeding _______________ per _______________.                                   Fee terms: Collect  Prepaid  Customer check acceptable 
             Note: Liability limitation for loss or damage in this shipment may be applicable. See 49 USC § 14706(c)(1)(A) and (B).
Received, subject to individually determined rates or contracts that have been agreed        The carrier shall not make delivery of this shipment without payment of charges and
upon in writing between the carrier and shipper, if applicable, otherwise to the rates,
classifications, and rules that have been established by the carrier and are available to
                                                                                             all other lawful fees.
the shipper, on request, and to all applicable state and federal regulations.                Shipper Signature ________________________________________________________
Shipper Signature/Date                                            Trailer Loaded:            Freight Counted:                                    Carrier Signature/Pickup Date
                                                                   By shipper                By shipper
 _________________________________________                                                                                                        ________________________________________
                                                                   By driver                 By driver/pallets said to contain
This is to certify that the above named materials are                                                                                            Carrier acknowledges receipt of packages and required
properly classified, packaged, marked, and labeled, and are                                   By driver/pieces                                  placards. Carrier certifies emergency response information
in proper condition for transportation according to the                                                                                          was made available and/or carrier has the DOT emergency
applicable regulations of the DOT.                                                                                                               response guidebook or equivalent documentation in the
                                                                                                                                                 vehicle. Property described above is received in good order,
                                                                                                                                                 except as noted.