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 _______________.
Liability limitation for loss or damage in this shipment may be applicable. See 49 USC § 14706(c)(1)(A) & (B)
Received, subject to individually determined rates or contracts that have been agreed 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 the shipper, on request, and to all applicable state and federal regulations.
The carrier shall not make delivery of this shipment without payment of charges & all other lawful fees
Shipper Signature ____________________
Trailer Loaded: __ By shipper __ By driver Freight Counted:__ By shipper__ By driver/pallets said to contain __ By driver/pieces
Shipper Signature/Date
______________________________ This is to certify that the above named materials are properly classified, packaged, marked, and labeled, and are in proper condition for transportation according to the applicable regulations of the DOT.
Carrier Signature/Pickup Date
__________________________ Carrier acknowledges receipt of packages and required placards. Carrier certifies emergency response information was made available and/or carrier has the DOT emergency response guidebook or equivalent documentation in the vehicle. Property described above is received in good order, except as noted.
