Wheels Carrier Profile Form

Please complete the following form & E-mail: Fax: 905.602.2818

NOTE: If you have an existing carrier profile form, please attach and send to email indicated above or fax.

1.  Will you fax / email Wheels when you have availability? Yes No

2.  Are you interested in receiving our daily rundown? Yes No

Part I. General Information

Carrier Name:

Address:

City: Province / State:

Country: Postal / Zip:

Contact Name:

Main 800#: X Fax:

Dispatch #: X Fax:

After hours: X Fax:

Email 1. Email 2.

Hours of Operations:

Website: http://www.

Part II. Required profile information: (Please provide copies to Wheels where applicable)

Send Insurance / Operating Authorities: Yes No

Send WSIB / CST Certificate of Clearance: Yes No

Communication with driver: Cell Sat Other

Name Wheels International as Insurance Certificate Holder: Yes No

US Bonded: Yes No Canadian Bonded: Yes No Surety Bonded: Yes No

US Bond #: CDN Bond #: Surety Bond #:

NIR# (PQ Only):

ICC#: IRS#: SCAC#:

SVI#: E-Manifest#:

Part III. Other Certificates: (Please provide copies to Wheels where applicable)

C-TPAT? Yes No CSA? Yes No PIP? Yes No FAST: Yes No

Hazmat CDN? Yes No Hazmat USA? Yes No

Emergency Response Contact #:

Part III. Driver & Equipment Type & Quantity Information:

Number of Company Drivers: Number of Owner Operators:

T/L? Yes No LTL? Yes No Both? Yes No

Reefers? Yes No Heaters? Yes No

Equipment Type / Quantity / Equipment Type / Quantity
53’ DV Yes No / / Step decks Yes No /
48’ DV Yes No / / Ramp & Tarp Yes No /
53’ Reefer Yes No / / Straight Truck Yes No /
48’ Reefer Yes No / / Pups/B-trains Yes No /
53’ Plate Yes No / / Tridem Yes No /
48’ Double Drop Yes No / / Quads Yes No /
Flatbeds Yes No / / Power tailgate Yes No /
Container Chassis Yes No / / Power Units Yes No /
Bulk Tanker Yes No / / Other Yes No /

Part IVb. Licensing Information – Areas of Strength in the United States

Alabama / Louisiana / Ohio
Alaska / Maine / Oklahoma
Arizona / Maryland / Oregon
Arkansas / Massachusetts / Pennsylvania
California / Michigan / Rhode Island
Colorado / Minnesota / South Carolina
Connecticut / Mississippi / South Dakota
Delaware / Missouri / Tennessee
District of Columbia / Montana / Texas
Florida / Nebraska / Utah
Georgia / Nevada / Vermont
Hawaii / New Hampshire / Virginia
Idaho / New Jersey / Washington
Illinois / New Mexico / West Virginia
Indiana / New York State / Wisconsin
Iowa / New York City / Wyoming
Kansas / North Carolina
Kentucky / North Dakota

Part IVb. Licensing Information – Areas of Strength in Canada

British Columbia / NW Territories / New Brunswick
Alberta / Yukon / Newfoundland
Manitoba / Ontario / Nova Scotia
Saskatchewan / Quebec / Nunavut
Labrador / Prince Edward Island

Comments: (IE Expedite? / Intermodal ? / Team service? )

CO01-04.13