New Truck Haul Application If you are a human and are seeing this field, please leave it blank. Company Name Owner's Name Billing Address City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Business Phone Cell Phone Fax Number Email Dispatcher's Name Dispatcher's Phone Number Quantity of Tandem Trucks 0 1 2 3 4 5+ Tandem Truck Haul Types AsphaltStoneDirtRiprapConcreteWet Batch Quantity of Semi-Tractors 0 1 2 3 4 5+ Semi-Tractor Trailer Types FlowSteel TubDump List quantity of truck types, trailer types, and what they can haul. (Haul Examples: Asphalt, Stone, Dirt, RipRap, Concrete, Wet Batch) Owner/Operator? If using hired drivers, please list their names. In addition to this submitted form please fax insurance certificates to Brandt Construction Co. at 309-787-6344 ATTN: Truck Application.