Please fill in the information below.
Be sure to click the "Submit Request" button. A Haines Transportation representative will contact you shortly to complete the process.

Bold fields marked with an asterisk (*) are required.

1. Your Name and Name of Company: *
2. Your Address *
3. Description of your Truck (3 axles only, please): *
4. Your Phone Number for contact: *
5. Your Email address:  
6. What lane activity are you seeking? (California only? 11 Western States? )
   Please describe: *
7. May we ask how you heard about us?  
8. Do you have your own General Liability insurance, or will you be asking us to provide you with insurance? Please provide your insurance information if you have your own: (Company and policy number please):  
9. Do you have Cargo Coverage Insurance, or will you be asking us to provide? Please provide policy limit if you have your own:  
10. Do you have a California DMV Motor Carrier Permit, or Interstate Authority (MC#), or will you be using our authority? (If using yours, please provide info and number):  
11. Are you enrolled in a Third Party Drug Testing Consortium? (If YES, please provide company and info):  
12. Security Code: *
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