Secured Transport Inc

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General Shipping Information

Estimated Date of Move

Carrier Type

Quote or Customer Id Number:

- Found in quote email. Example: 505310019

Customer Name:

- The name of the person arranging the transport.

Customer Phone Number:

Origin Information

Origin Contact Name:
Contact Phone:
Other Phone:	(optional)
Street:
	(optional)

Origin City:

Origin State:

Zip Code

Destination Information

Destination Contact Name:
Contact Phone:
Other Phone:	(optional)
Street:
	(optional)

Destination City:

Destination State:

Zip Code

Vehicle Information

Vehicle

Last 6 of VIN:

Year:

Make:

Model:

Color:

One

Two

Please Describe Vehicle Running Condition:

Authorization and Agreement to Terms

Yes, I have received, read and understand the shipping agreement general previsions of Secured Transport, Inc. I agree to pay the shipping cost agreed upon in the quote and understand that the deposit is non-refundable. I also understand that the COD amount must be paid upon receipt of the vehicle and that only cash or cashiers checks are accepted for the COD.