|
MC-198204 DOT #045106 |
- Since 1959 - Nation-Wide Horse Transportation, Inc.719-392-1888 Fax: 719-392-1891 AUTHORIZATION FORM please print or type |
Please enclose directions for pickup & delivery |
|
OWNER INFORMATION Name_______________________________________________________ Stable/Farm/Ranch_____________________________________________ Address_____________________________________________________ City & State__________________________________________________ PICKUP INFORMATION (if different than owner) Name_______________________________________________________ Stable/Farm/Ranch_____________________________________________ Address_____________________________________________________ City & State__________________________________________________ DELIVERY INFORMATION (if different than owner) Name_______________________________________________________ Stable/Farm/Ranch_____________________________________________ Address_____________________________________________________ City & State_________________________________________________ |
PHONES Home___________________________ Office___________________________ Stable___________________________ Cell_____________________________ PHONES Home___________________________ Office___________________________ Stable___________________________ Cell_____________________________ PHONES Home___________________________ Office___________________________ Stable___________________________ Cell_____________________________ |
HORSE INFORMATION (*M=Mare S=Stallion G=Gelding F=Filly C=Colt)
|
Breed |
Sex* |
Age |
Color, markings, brand, etc. |
Name |
Value |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
SPECIAL INSTRUCTIONS OR COMMENTS ON HORSE TEMPERAMENT OR CONDITIONS:
TACK OR EQUIPMENT TO BE TAKEN: (Call for quote.)
TIME FRAME REQUESTED FOR SHIPPING: ____________________________________
|
PAYMENT: Transportation Cost $____________________ Tack $____________________ TOTAL $____________________ Deposit $____________________ Balance due on Pick-up or delivery $____________________ (mark one) |
AUTHORITY: I have read this entire document and the terms and conditions on Page 1, understand it completely, and agree to be bound by its terms in its entirety. I understand and agree to accept the risks of shipping my horse(s). I authorize veterinarian care at my expense should it be necessary. SIGNATURE (SHIPPER/OWNER/AGENT) _____________________________________________ DATE________________________________________ |
Page 2 of 2