Carrier’s Pro No.
Shipper’s Bill of Lading No.
Consignee’s Reference/PO No.
Name of Carrier Carrier’s Code (SCAC)

RECEIVED, subject to individually determined rates or contracts that have been agreed upon in writing between ther carrier and shipper, if applicable, otherwise to rates, classification and rules that have been established by the carrier and are available to the shipper, on request;

From Date Street City County State zip

the property described below, in apparent good order, except as noted (contents and condition of contents of packages unknown) marked, consigned, and destined as shown below, which said carrier agrees to carry to destination, if on its route, or otherwise to deliver to another carrier on the route to destination. It is mutually agreed, as to each carrier of all or any of said property over all or any portion of said route to destination, and as to each party at any time interested in all or any of said property, that every service to be preformed hereunder shall be subject to all the terms and conditions of the Uniform Bill of Lading set forth in the National Motor Freight Classification 100-x and successive issues. The shipper hereby certifies that he is familiar with all the terms and conditions of the said bill of lading, including those on the back thereof, and the said terms and conditions are hereby agreed to by the shipper and accepted for himself and his assigns.

Consigned to
On Collect on Delivery Shipments, the letters “COD” must appear before consignee’s name.

Destination Street
City County State Zip Delivering Carrier Trailer No. Additional Shipment Information

Collect on Delivery $
Street City State
C.O.D. charge Shipper

to be paid by Consignee

Kind of Package, Description of Articles, Special Marks and Exceptions
(Subject to correction)
(subject to
Clas or
Rate Ref.
(For Info. Only)
Freight charges are PREPAID
unless marked collect.
If this shipment is to be delivered to the consignee, without recourse on the consignor, the consignor shall sign the following statement: The carrier may decline to make delivery of this shipment without payment of the freight and all other lawfull charges.

(Signature of Consignor)

star Mark to designate Hazardous Materials as defined in Department of Transportation Regulations.

NOTE (1) Where the rate is dependent on value, shippers are required to state specifically in writing the
agreed or 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 .”

NOTE (2) Liability Limitation for loss or damage on this shipment
may be applicable. See 49 U.S.C. § 14706(c)(1)(A) and (B).

NOTE (3) 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 Sec. 2(e) of NMFC Item 360.
Notify if problem enroute or at delivery (for informational purposes only)
Name Fax No. Tel. No
Send freight bill to:
Company Name Address City State Zip
Shipper Carrier
Per Per Date

Shipper Certification Carrier Certification
This is to certify that the above named materials are properly classified, described, packaged, marked and labeled, and are in proper condition for transportation according to the applicable regulations of the Department of Transportation.
Per Date
Carrier acknowledges receipt of packages and required placards. Carrier certifies emergency response information was made available and/or carrier has the Department of Transportation emergency response guidebook or equivalent document in the vehicle.
Per Package Nos.