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<title>Bill of Lading</title>
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#commodity {width:43em}
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</style>
</head>
<body>
<h1>Bill of Lading</h1>
<form action="" method="post" accept-charset="utf-8" id="bol">
<fieldset class="simple">
<legend><span>Date</span></legend>
<label for="date">Date:</label> <input type="text" name="date" id="date">
</fieldset>
<div id="wrapper-1">
<div id="addresses">
<fieldset class="address">
<legend><span>Ship From</span></legend>
<div>
<label for="sf-name">Name:</label> <input type="text" name="sfName" id="sf-name">
<br><label for="sf-address">Address:</label> <input type="text" name="sfAdress" id="sf-address">
<br><label for="sf-city">City/State/Zip:</label> <input type="text" name="sfCity" id="sf-city">
<br><label for="sf-sid"><abbr>SID</abbr>#:</label> <input type="text" name="sfSID" id="sf-sid">
<label for="sf-fob"><abbr>FOB</abbr>:</label> <input type="checkbox" value="Y" name="sfFOB" id="sf-fob">
</div>
</fieldset>
<fieldset class="address">
<legend><span>Ship To</span></legend>
<div>
<label for="st-name">Name:</label> <input type="text" name="stName" id="st-name">
<label for="st-location">Location #:</label> <input type="text" name="stLocation" id="st-location">
<br><label for="st-address">Address:</label> <input type="text" name="stAdress" id="st-address">
<br><label for="st-city">City/State/Zip:</label> <input type="text" name="stCity" id="st-city">
<br><label for="st-contact">Contact:</label> <input type="text" name="stContact" id="st-contact">
<label for="st-fob"><abbr>FOB</abbr>:</label> <input type="checkbox" value="Y" name="stFOB" id="st-fob">
</div>
</fieldset>
<fieldset class="address">
<legend><span>Third Party Freight Charges Bill To</span></legend>
<div>
<label for="tpf-name">Name:</label> <input type="text" name="tpfName" id="tpf-name">
<br><label for="tpf-address">Address:</label> <input type="text" name="tpfAdress" id="tpf-address">
<br><label for="tpf-city">City/State/Zip:</label> <input type="text" name="tpfCity" id="tpf-city">
</div>
<div>
<label for="tpf-instructions">Special Instructions:</label> <textarea name="tpfInstructions" rows="2" cols="30" id="tpf-instructions"></textarea>
</div>
</fieldset>
</div>
<div id="admin">
<fieldset class="simple barcode">
<legend></legend>
<label for="bol-no">Bill of Lading Number/<abbr>PO</abbr> #:</label> <input type="text" name="bolNo" id="bol-no">
</fieldset>
<fieldset class="columnar">
<legend><span>Carrier</span></legend>
<div>
<label for="carrier-name">Carrier name:</label> <input type="text" name="carrierName" id="carrier-name">
<br><label for="trailer-no">Trailer number:</label> <input type="text" name="trailerNo" id="trailer-no">
<br><label for="seal-no">Seal number(s):</label> <input type="text" name="sealNo" id="seal-no">
</div>
</fieldset>
<fieldset class="columnar barcode">
<legend><abbr>SCAC</abbr></legend>
<div>
<label for="scac"><abbr>SCAC</abbr>:</label> <input type="text" name="scac" id="scac">
<br><label for="pro">Pro number:</label> <input type="text" name="pro" id="pro">
</div>
</fieldset>
<fieldset id="fct">
<legend><span>Freight Charge Terms: <small>(freight charges are prepaid unless marked otherwise)</small></span></legend>
<div>
<label for="fct-prepaid">Prepaid</label> <input type="text" name="fctPrepaid" id="fct-prepaid">
<label for="fct-collect">Collect</label> <input type="text" name="fctCollect" id="fct-collect">
<label for="fct-3rd-party">3rd Party</label> <input type="text" name="fct3rdParty" id="fct-3rd-party">
</div>
<div>
<div>
<input type="checkbox" value="Y" name="fctCB" id="fct-cb">
<label for="fct-cb">(check box)</label>
</div>
<p>Master Bill of Lading: with attached underlying Bills of Lading</p>
</div>
</fieldset>
</div>
</div>
<table id="coi">
<caption>Customer Order Information</caption>
<thead>
<tr>
<th>Customer Order Number</th>
<th># <abbr>pkgs</abbr></th>
<th>Weight</th>
<th>Pallet/Slip <small>(circle one)</small></th>
<th>Additional Shipper Info</th>
</tr>
</thead>
<tfoot>
<tr>
<th>Grand Total:</th>
<td>1 <abbr>plts</abbr></td>
<td>50 lbs</td>
</tr>
</tfoot>
<tbody>
<tr><td></td><td></td><td></td><td></td><td></td></tr>
</tbody>
</table>
<table>
<caption>Carrier Information</caption>
<thead>
<tr>
<th colspan="2">Handling Unit</th>
<th colspan="2">Package</th>
<th rowspan="2">Weight</th>
<th rowspan="2"><abbr>H.M.</abbr> (X)</th>
<th rowspan="2" id="commodity">
Commodity Description
<small>Commodities requiring special or additional care or attention in handling or stowing must be so marked and packaged as to ensure safe transportation with ordinary care.</small>
<cite>See Section 2(a) of <abbr>NMFO</abbr> item 360</cite>
</th>
<th colspan="2"><abbr>LTL</abbr> Only</th>
</tr>
<tr>
<th><abbr>Qty</abbr></th>
<th>Type</th>
<th><abbr>Qty</abbr></th>
<th>Type</th>
<th><abbr>NMFC</abbr> #</th>
<th>Class</th>
</tr>
</thead>
<tbody>
<tr><td>1</td> <td><abbr>PLTS</abbr></td> <td>3</td> <td>CASES</td> <td>50 LBS</td> <td></td> <td></td> <td></td> <td>65</td></tr>
<tr><td> </td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr>
</tbody>
</table>
<fieldset id="cod">
<legend></legend>
<label for="cod-amount"><abbr>COD</abbr> Amount: $</label> <input type="text" name="codAmount" id="cod-amount">
<br><label for="cod-fee">Fee Terms: Collect: Prepaid:</label> <input type="checkbox" value="Y" name="codFee" id="cod-fee">
<br><label for="cod-check">Customer check acceptable:</label> <input type="checkbox" value="Y" name="codCheck" id="cod-check">
</fieldset>
<fieldset class="simple">
<legend></legend>
<label for="value">
When the rate is dependent on value, shippers are required to state specifically in writing the agreed or declared value of the property as follows:
<br>The agreed or declared value of the property is specifically stated by the shipper to be not exceeding
</label>
<input type="text" name="value" id="value">
<label for="value-per">per</label>
<input type="text" name="valuePer" id="value-per">
</fieldset>
<p id="liability">Note Liability Limitation for loss or damage in this shipment may be applicable. See <cite>49 <abbr>U.S.C.</abbr> 14706(c)(1)(A) and (B)</cite>.</p>
<div id="wrapper-2">
<p>RECEIVED, subject to individually determined rates or contracts that have been agreed upon in writing between the carrier and shipper, if applicable,
otherwise to the rates, calssifications and rules that have been established by the carrier and are available to the shipper, on rquest,
and to all applicable state and federal regulations.</p>
<fieldset id="payment">
<legend><span>The carrier shall not make delivery of this shipment without payment of freight and all other lawful charges.</span></legend>
<input type="text" readonly id="shipper-signature"> <label for="shipper-signature">Shipper Signature</label>
</fieldset>
</div>
<div id="wrapper-3">
<div id="ssd">
<h2>Shipper Signature Date</h2>
<p>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 <abbr>U.S. DOT</abbr>.</p>
</div>
<div id="tlfc">
<fieldset>
<legend>Trailer Loaded:</legend>
<input type="checkbox" value="Y" name="loadedByShipper" id="loaded-by-shipper"> <label for="loaded-by-shipper">By Shipper</label>
<br><input type="checkbox" value="Y" name="loadedByDriver" id="loaded-by-driver"> <label for="loaded-by-driver">By Driver</label>
</fieldset>
<fieldset>
<legend>Freight Counted:</legend>
<input type="checkbox" value="Y" name="countedByShipper" id="counted-by-shipper"> <label for="counted-by-shipper">By Shipper</label>
<br><input type="checkbox" value="Y" name="countedByDriverPallets" id="counted-by-driver-pallets"> <label for="counted-by-driver-pallets">By Driver/pallets said to contain</label>
<br><input type="checkbox" value="Y" name="countedByDriverPieces" id="counted-by-driver-pieces"> <label for="counted-by-driver-pieces">By Driver/Pieces</label>
</fieldset>
</div>
<div id="cspd">
<h2>Carrier Signature/Pickup Date</h2>
<p>Carrier acknowledges receipt of packages and required placards.
Carrier certifies emergency response information was made available and/or carrier has the <abbr>U.S. DOT</abbr> emergency/response guidebook or equivalent
documentation in the vehicle.</p>
<p>Property described above is received in good order, except as noted.</p>
</div>
</div>
<fieldset id="sign">
<legend><span>Signature</span></legend>
<label for="sign-print">Print Name:</label> <input type="text" name="signPrintName" id="sign-print">
<label for="sign-sign">Sign:</label> <input type="text" readonly id="sign-sign">
<label for="sign-date">Date:</label> <input type="text" name="signDate" id="sign-date">
</fieldset>
</form>
</body>
</html>
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