SHIPPER  (FROM):

  Date

ADDRESS:

CONSIGNEE (TO):

DESTINATION                         State            County                    Address

ROUTE:                                                                                                                                                                  

     VEHICLE  No.          

________________________________________________________________________________________________________________________

FREIGHT CHARGES   PREPAID  COLLECT   THIRD PARTY

Collect On Delivery $    remit to

Street  City  State

THIRD PARTY BILLING:

________________________________________________________________________________________________________________________

No.                 (X)              Kind of package, description of articles,                                   Class/  

Packages       HM             special marks & exceptions                                   *Weight      Rate         Check

     C.O.D charge

      to be paid by:

     Shipper

     Consignee

  _____________

 (Signature of Consignor)

 If charges to be prepaid, write 

or stamp here: "To be prepaid"

  _____________

 Received $________

*(Subject to correction)     Mark (X) in "HM" column for HAZARDOUS materials                                           to apply in the prepayment of the

The agreed  or declared value of the property is hereby stated by the shipper                                       charges on property described hereon

to be not exceeding ____________________ per ______________                                 ______________

                                                                                                                                                                                                    ( agent or cashier)

________________________________________________________________________________________________________________________

__________________________________________________________ Shipper ___________________________________________ Agent

Per______________________________________________________________  Per________________________________________

Permanent Address of Shipper: ______________________________________________________

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