WERNER DE MEXICO

TRAILER #:      

TRIP NUMBER       PICK UP: Date:       Time:      

Contact:       Telephone: (     )      
SHIPPER
Name:      
Address:      
     
Telephone: (     )       FAX: (     )      
Contact:      
Commodity:      
Weight:      
US BROKER
Name:      
Address:      
     
Telephone: (     )       FAX: (     )      
Contact:      
MX BROKER
Name:      
Address:      
     
Telephone: (     )       FAX: (     )      
Contact:      
CONSIGNEE
Name: Werner Enterprises, Inc.
Address:      
      ZIP Code:      
Telephone: (     )       FAX: (     )      
Contact:      
BILL USA PORTION TO:
Name:      
Address:      
     
Telephone: (     )       FAX: (     )      
Contact:      
Amount:       Miles @       TOTAL: US$      
BILL MEXICAN PORTION TO:
Name:      
Address:      
     
Telephone: (     )       FAX: (     )      
Contact:      
RFC:      
Amount: US $       Standard Rate OTHER: US Cust.: $       Carrier: $      

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