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Pick-Up Date
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  Delivery Date 
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Sender's Account Number
Customer Ref. Number

 
Pick-Up Location Name
 
Dept./Floor #/Booth #
Delivery Location Name
 
Dept./Floor #/Booth #
From (Your Name):
 
Your Phone Number
 
 To (Recipient Name)
 
Recipient Phone #
 
Street Address
 
City
 
Street Address (No PO Box)
 
 City
 
State
 
Zip
 
State
 
Zip
 
Country
Country
Email
 
  Email
 
 
 Please check box for insurance:
SERVICE LEVELS (pick one)






OPTIONAL:

TOTAL PIECE COUNT INSURED VALUE DESCRIPTION WEIGHT
(Subject to dimensional correction) 
SPECIAL INSTRUCTIONS
TOTAL WEIGHT

Authorizing Name:  Date:  ...

US Express Freight Systems
3240 Hubbard Rd, Landover, MD 20785 USA
(800) 328-8000

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