SuperVan Service Co., Inc.

Shipper #
121 Bremen Avenue
St. Louis, MO 63147 Carrier #
Uniform Straight Bill of Lading
ORIGINAL Phone (314) 231-8444 Date
Fax (314) 436-3803

TO: FROM:
Consignee Shipper

Street Street

Destination Zip Code Origin Zip Code

Route Vehicle Number

Kind of Packaging, Description of Articles Weight Freight Charges
Class Pieces Hazmat Special Marks and Exceptions subject to correction are to be
FREIGHT PREPAID
Except when box below is checked

Check Box if Charges are to be

COLLECT
C.O.D. FEE AMOUNT
$

C.O.D. FEE COLLECT except when

box below is checked

Check Box if COD Fee is to be

PREPAID

REMIT C.OD. $
C.O.D. TO
ADDRESS

Shippers Certification Placards Required? Placards Provided?

This is to certify that the above named materials are
properly classified, described, packaged, marked and
labeled, and are in proper condition for transportation
according to the applicable regulations of the Department
Of Transportation. Per Yes No Yes No
SUBJECT TO SECTION 7: Of the conditions if shipment is to be delivered to consignee without recourse
on the consignor, the consignor shall sign the following statement: NOTE: The agreed or declared
The Carrier shall not make delivery of the shipment without payment of the freight and all other lawful value of property is hereby
charges. SIGNATURE OF THE CONSIGNOR: specifically stated by the shipper
Received, subject to individually determined rates or contracts that have been agreed upon in writing to be not exceeding
between the carrier and shipper, if applicable. Otherwise the rate classifications and rules that have
been established by the carrier and are available to the shipper, on request, shall apply as well as all applicable $ per cwt.
state and federal regulations.

SHIPPER CARRIER SuperVan Service Co., Inc.

PER SIGNATURE PER SIGNATURE

DATE/TIME DATE/TIME

7/23/2019