Dynamic Mobility Services LLC       Office (602) 763-4964              Fax (602) 484-0810

 Request for Third Party Services

BILLING INFORMATION
 Name:                Account #
 Address:  Apt/Suite #
 City:                  State:     
 Zip Code:           Phone #    
 Work #:                Fax #     
 Coordinator: Salesperson:

  BILLING INFORMATION cont.
 Registration #: Job #
 Rate Schedule:
 Bill To:   Agent   Vanline   COD
 Estimated Weight: 
 National Account:  
 Email Address :      
 SHIPPER INFORMATION
 Pack Date: 
 Load Date:  
 Del Date:     		 THIRD PARTY SERVICES ARE FOR:
 Origin         
 Destination 
 Both             
 Origin Request Date:    Check to use Billing Info
 Name:                        Address: 
 Apt/Suite #                       City: 
 State:                       Zip:    
 Home #:           Work #: 
 Other #:                 Fax #:  		 Destination Request Date:   
 Name:                        Address: 
 Apt/Suite #                       City: 
 State:                       Zip:    
 Home #:           Work #: 
 Other #:                 Fax #: 

Notes/Special Instructions

Click here for Pricing

 

Description

Length

Width

Height

  

Description

Length

Width

Height
1. 2.
3. 4.
5. 6.
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9. 10.
11. 12.
13. 14.

 Crates - 1x4 lumber with packing materials needed (E.G. cardboard, Styrofoam, & paper pads).

 ***PLEASE NOTE: SHOULD AN APPLIANCE BE A REFRIGERATOR, PARTS WILL NOT BE INCLUDED IN THE ABOVE
 LISTED RATES.

 ***PLEASE NOTE: SHOULD AN APPLIANCE BE AN ICEMAKER, THE FOLLOWING PARTS WILL BE SUPPLIED IN
 NECESSARY: WATER LINE, COMPRESSION NUTS AND FITTINGS.
 THIS WILL BE DONE AT THE RATE OF $40.00 ADDITIONAL.

 ***PLEASE NOTE: IN ACCORDANCE WITH NATIONAL SAFETY STANDARDS, ALL GAS APPLIANCES MUST AND
 WILL BE INSTALLED WITH THE FOLLOWING NEW PARTS:
 FLEX CONNECTOR & FITTINGS OF $37.00 ADDITIONAL
 PLUS LABOR (FOR INSTALLATION) OF $40.00 ADDITIONAL