8350 Whitcomb St. - Suite 1-A
Merrillville, IN 46410
Phone: 888-257-2677
Fax: 219-795-1456
CLR@CLRAutoTransport.com


Shipping Request Form


All fields marked with an asterik (*) are required.
 
Part 1 - Vehicle Information and Availability
Vehicle #1
Transportation via (select one)*:   Open Carrier   Closed 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:
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.