[Date]	BILL OF LADING – SHORT FORM – NOT NEGOTIABLE	Page 1 of 1

SHIP FROM	Bill of Lading Number: _____________________________
[Name] [Street Address] [City, ST ZIP Code] SID No.: __________________	BAR CODE SPACE
SHIP TO	Carrier Name: _____________________________
[Name] [Street Address] [City, ST ZIP Code] SID No.: __________________	Trailer number: __________________ Serial number(s): __________________
THIRD PARTY FREIGHT CHARGES BILL TO	SCAC: _____________________________
[Name] [Street Address] [City, ST ZIP Code]	Pro Number: __________________ BAR CODE SPACE
Special Instructions: [Instructions]	Freight Charge Terms (Freight charges are prepaid unless marked otherwise):

CUSTOMER ORDER INFORMATION

Customer Order No.	# of Packages	Weight	Pallet/Slip	Additional Shipper Information
Grand Total

Carrier INFORMATION

Handling Unit	Package	LTL Only

Qty	Type	Qty	Type	Weight	HM (X)	Commodity Description 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	NMFC No.	Class

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 ______________.	COD Amount: $ ____________	Fee terms:

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 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 and all other lawful fees. Shipper Signature ________________________________________________________

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.	Trailer Loaded:	Freight Counted:	Carrier Signature/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.