CLR Auto Transport
8350 Whitcomb Street
Suite A, B & C
Merrillville, Indiana 46410
Phone: 1-888-257-2677
1-219-795-1040
Fax: 1-219-795-1456
Email:
CLR@CLRAutoTransport.com
Shipping Order Form
To download a faxable form
Click Here
.
Otherwise, use the electronic form below.
All fields marked with an asterik (
*
)
are required.
Part 1 - Vehicle Information and Availability
Vehicle #1
Transportation via (select one)
*
:
Open Carrier
Enclosed Carrier
Professional Drive Away
Is the vehicle in running condition?
Yes
No
Year
*
:
Make
*
:
Model
*
:
Color:
License Plate# (if available):
Vin #
*
:
Registered Owner
*
:
Vehicle #2
Transportation via (select one)
*
:
Open Carrier
Enclosed Carrier
Professional Drive Away
Is the vehicle in running condition?
Yes
No
Year
*
:
Make
*
:
Model
*
:
Color:
License Plate# (if available):
Vin #
*
:
Registered Owner
*
:
Vehicle #3
Transportation via (select one)
*
:
Open Carrier
Enclosed Carrier
Professional Drive Away
Is the vehicle in running condition?
Yes
No
Year
*
:
Make
*
:
Model
*
:
Color:
License Plate# (if available):
Vin #
*
:
Registered Owner
*
:
Vehicle #4
Transportation via (select one)
*
:
Open Carrier
Enclosed Carrier
Professional Drive Away
Is the vehicle in running condition?
Yes
No
Year
*
:
Make
*
:
Model
*
:
Color:
License Plate# (if available):
Vin #
*
:
Registered Owner
*
:
Vehicle #5
Transportation via (select one)
*
:
Open Carrier
Enclosed Carrier
Professional Drive Away
Is the vehicle in running condition?
Yes
No
Year
*
:
Make
*
:
Model
*
:
Color:
License Plate# (if available):
Vin #
*
:
Registered Owner
*
:
Vehicle #6
Transportation via (select one)
*
:
Open Carrier
Enclosed Carrier
Professional Drive Away
Is the vehicle in running condition?
Yes
No
Year
*
:
Make
*
:
Model
*
:
Color:
License Plate# (if available):
Vin #
*
:
Registered Owner
*
:
Vehicle #7
Transportation via (select one)
*
:
Open Carrier
Enclosed Carrier
Professional Drive Away
Is the vehicle in running condition?
Yes
No
Year
*
:
Make
*
:
Model
*
:
Color:
License Plate# (if available):
Vin #
*
:
Registered Owner
*
:
Vehicle #8
Transportation via (select one)
*
:
Open Carrier
Enclosed Carrier
Professional Drive Away
Is the vehicle in running condition?
Yes
No
Year
*
:
Make
*
:
Model
*
:
Color:
License Plate# (if available):
Vin #
*
:
Registered Owner
*
:
Vehicle #9
Transportation via (select one)
*
:
Open Carrier
Enclosed Carrier
Professional Drive Away
Is the vehicle in running condition?
Yes
No
Year
*
:
Make
*
:
Model
*
:
Color:
License Plate# (if available):
Vin #
*
:
Registered Owner
*
:
Vehicle #10
Transportation via (select one)
*
:
Open Carrier
Enclosed Carrier
Professional Drive Away
Is the vehicle in running condition?
Yes
No
Year
*
:
Make
*
:
Model
*
:
Color:
License Plate# (if available):
Vin #
*
:
Registered Owner
*
:
Part 2 - Pick Up Information
Contact Name - First
*
:
Last
*
:
Pick up address
*
:
City
*
:
State
*
:
Zip Code:
Phone
*
:
Cell Phone:
Email:
Part 3 - Delivery Information
Contact Name - First
*
:
Last
*
:
Delivery address
*
:
City
*
:
State
*
:
Zip Code:
Phone
*
:
Cell Phone:
Email:
Part 4 - Customer Contract Terms and Conditions
By typing in the signature field in this section (Part 4), you acknowledge that you have fully read our "
Customer Contract Terms and Conditions
" and fully understand this agreement.
To read the "
Customer Contract Terms and Conditions
"
CLICK HERE
.
I have read and agree to the "
Customer Contract Terms and Conditions
"
*
.
Customer Signature
*
:
Date (mm/dd/yyyy)
*
:
Part 5 - Transportation Cost and Method Payment
The total cost to ship your vehicle(s) is
*
:$
Amount to be charged today (deposit or full amount)
*
:$
IMPORTANT REMARKS: Only a deposit is required when you place the order, however, you may pay the full amount. if you choose to pay only a deposit, the balance must be paid in either cash ot certified check upon delivery of your vehicle.
If you would like to pay the full amount via credit card, A SURCHARGE OF 3% WILL BE ADDED.
We accept the following forms of payment:
Payment Method:
Visa
Mastercard
Discover
American Express
Telecheck
Credit Card Number (no spaces):
Expiration Date (mm/yy):
Name as it appears on card:
Last three digits on the back of card (security digits):
Customer (Shipper) Signature
*
:
Date (mm/dd/yyyy)
*
:
Phone
*
:
Cell Phone:
Email:
Additional Information/Comments:
IMPORTANT REMARK: ICC regulation prohibits any deductions from the amount of this bill and requires payment in full to the carrier.
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Copyright ©2005 CLR Auto Transport
