Customer Details
Customer / Company Name
Contact Name
Phone Number
Customer E-mail Address
*
example@example.com
Pickup Details
Request Date and time to pickup
Company Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Name
Collection Phone #
Delivery Details
Company Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Name
Additional Information
Product Details
Transport Requirements
Pickup / Deliver Pallet(s)
Truck Hire
Other
Brief description of requirements
Is a tail lift requred?
Please Select
Yes
No
Weight of the goods
Cubic Measurement of the goods.
(Height * Width*Length)
Photo of Product
Browse Files
Drag and drop files here
Choose a file
Cancel
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Are any of the product items classed as Dangerous Goods?
Yes
No
Dangerous Goods Class
Please Select
Class 1 - Explosives
Class 2.1 - Flammable Gas
Class 2.2 - Non Flammable Gas
Class 2.3 - Toxic Gas
Class 3 - Flammable Liquid
Class 4.1 - Flammable Solid
Class 4.2 Spontaneously Combustible
Class 4.3 - Dangerous When Wet
Class 5.1 - Oxidizing Agent
Class 5.2 - Organic Peroxide
Class 6.1 - Toxic
Class 6.2 - Infectious Substance
Class 7 - Radioactive
Class 8 - Corrosive
Class 9 - Miscellaneous D.G.'s
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