Dieheart Trucking Inc., Woodlands Houston Texas Page 3 Place Order

Online Place Order Form

Today's Date: (format: Jan 01 2007) :.Purchase Order No.::
Type of Truck: Load Abbreviation:

Number of Trucks:

Your Company Name.....:
Your Company Address:
...City: ...State: ...ZipCode:
Your Contact Phone Number:
Your Fax Number:
Order Placer Name:

Date of Pickup (format: Jan 01 2007) : Day:(format: Monday) Time:(format: 1:00pm)
Pickup Business Name..:
Pickup Location Address:
Pickup City: Pickup State: Pickup ZipCode:
Pickup Business Phone Number:
Pickup Contact Phone Number:
Pickup Contact Person:

----------------------------------*Extra Stop*-------------------------------------------------------
...Extra Stop Site Pickup Date (format: Jan 01 2007) :
Day (format: Monday) : Time (format: 1:00pm) :
...Extra Stop Company Name:
...Extra Stop Location Address:
...Extra Stop City: State: ZipCode:
...Extra Stop Site Contact Phone Number:
...Extra Stop Site Contact Person Name:
----------------------------------*Extra Stop*-------------------------------------------------------

Delivery Date: (format: Jan 01 2007) : Day:(format: Monday) Time:(format: 1:00pm)
Delivery Business Name..:
Delivery Location Address:
Delivery City: Delivery State: Delivery ZipCode:
Delivery Business Phone Number:
Delivery Contact Phone Number:
Delivery Contact Person:

$Cost Per Truck: $Extra Stop Cost:

Input Boxes are variable in length and do not have to be filled
Make any comments you'd like below.:

Thanks for your input

We allow (2) Hours on each end for loading, each additional hour is $100.00.
For your approval, please sign and fax back at your earliest convenience to 281-292-6222.

Dieheart Trucking Inc.,
2301 S. Millbend Drive Suite 2111
The Woodlands, (Houston) Texas 77380
Phone: (713)-429-4434
Fax: (281)-292-6222

Email diehearttrucking@yahoo.com

Please email or call us if you have any questions.

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