To apply, please take a moment to fill-out the form below.

Company Information * Indicates Required Fields Agent of Record* Agency/Company Name* Mailing Address*

City* State/Province* -- Select -- AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY AB BC MB NB NF NS ON PE PQ SK NT YT ZIP Code*

Physical/Street Address (if different from mailing)

City* State/Province* -- Select -- AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY AB BC MB NB NF NS ON PE PQ SK NT YT ZIP Code* If corporation*, enter Federal ID Number

Contact Information Telephone Numbers*  (Two contact numbers required) Area Phone No. Ext. Type Office Home Pager Cell Fax Toll-Free Office Home Pager Cell Fax Toll-Free Office Home Pager Cell Fax Toll-Free

E-mail Address* Dispatcher(s):* Dispatch Telephone* Area Phone No. Ext. Type Office Home Pager Cell Fax Toll-Free Dispatch E-mail*

Personal Information Home Address* City* State/Province* -- Select -- AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY AB BC MB NB NF NS ON PE PQ SK NT YT ZIP Code* Birthdate*   (MM/DD/YYYY) Driver's License Number* State of Issue*

Home Telephone* Area Phone No. Ext. Type Office Home Pager Cell Fax Toll-Free

* Q1. Where is your business going to be located? (Home, office, etc.) * Q2. What kind of Internet connection do you have? (Dial-up, DSL, cable, etc.) Q3. List any current or prior agency affiliations that you wish to tell us about: * Q4. What type of freight do you move? * Q5. What type of equipment do you use most? * Q6. How much freight do you currently broker, in terms of loads per month? * Q7. How much freight do you broker, in terms of sales revenue per month? * Q8. What was your gross revenue last year? * Q9. What is your current average gross profit margin (%)? * Q10. What are you projecting your annual gross revenue will be when you join Extra Mile? * Q11. How many loads do you project you will move the first month with Extra Mile? * Q12. Why are you interested in joining Extra Mile Transportation? * Q13. What can we do to make you successful in this new business venture? * Q14. How did you find us? Q15. Could you refer someone else? Please provide their name and contact information here: (Extra Mile pays a generous bounty for agents signed by referral. Please provide referrer name and contact information.)

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