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Date Sec Req'd: 3-? :~- 7 am/pm <br />Pack Date: am/pm <br />Daivery Date Req'd: -~ F(;_~' am/pm <br />Order Taken By: (}Zt <br />j ~L~~:~f~. ~ 6/~~~ ~la~l~Jii~i~ <br />1455 Joir.son St. NE, ~~':s~~, CR 973, <br />(:.03) 5f31-oS3:i 0 ($UO) 823-tc41 • .'~,•: (603) <br />PUC Ju37342 • iCC ~~iC 22: 34~ <br />~-; _ - . ;- <br /> <br />NAME <br />p„ qT" '' ' T.,'" NAME <br />u LT T~ ~ <br />ADDRESS <br />~'~ i:' . TR~'~ "T: C "T ;t <br />. ADDRESS • <br />', <br />CITY <br />STATE ZIP <br />C T :'~t ~~ CITY <br />CONTACT PHONE <br />~; i '~' FAX CONTACT <br />I ~ ~ ~ I ~ ~ ~ I ~ ~ ~ I ~ ~ ~~ ~ ~ ~ I ~ ~ ~ I ~ ~ ~ I ~ ~ ~ I ~ ~ ~ I ~ ~ ~ I <br />6AM 7 8 9 10 17 12 1 2 3 <br />4 <br />NOON <br />EXPLANATION: P-PACKING L-LOADING D-DRIVING UL-UNLOADING UP-UNPACKIN( <br />MATERIALS MATEFIIAL PACKING UNPACKING AMOUNT <br /> QTY. RATE ~Tl(. RATE ~TY. RATE 1 TRUC <br />BARRELS/DISHPACKS ~ ~ ~ TRt1CK <br />CRATES/CONTAINERS EXTRA <br />CARTONS: 15 CU FT. 1 i^(? _~ _ /,'i', ,,'~ ; MATERI <br />3.0 CU FT ~' ~} ~, ` tJ) .,J,~ OTHER <br />4.5 CU FT 'V„ ~ ! , .: ; i - ~ . ,, <br />6.0 CU FT <br />WARDROBE CARTON <br />MIRROR CARTON <br />MATTRESS CTNS: SING~E <br />DOUBLE <br />QrHER <br />OTHER: -~' ~ _ ^r, ,~ ~ <br /> <br />SUBTOTAL - ~ ~ <br />. . . <br />if the shipper declines to sign this declaration of value and the shipment is accepted, <br />the shipment will move at the depreciated value protection level and the shipper will ' .., ~ <br /> <br />DATE OF PICKUP REQUE; <br />be subject to the appropriate valuation charges. <br />^ RELEASED VALUE PiiOTECTION: si~rraruRe~n~ReeMeNr n <br />Goods will be valued at 60 cents per Ib. per article. <br />Shipper: D <br />t <br />GROSS WT <br />a <br />e: MILES: <br />^ DEPRECIATED VALUE PROTECTION: Goods wili be valued at $1.25 times the <br />actual wei <br />ht of the shi <br />ment <br />For each $100 <br />00 <br />f <br />ti <br />th <br />f <br />f <br />l <br />g <br />p <br />. <br />, or <br />rac <br />. <br />on <br />ereo <br />, o <br />dec <br />ared value <br />at $1.25 times the weight of the shipment in Ibs. or declared fump sum value, whichever CHARGES FROM A& <br />is higher, the valuation charge shall be 50 cents per each $100.00 of value. CITHER CHARGES <br />Shipper: Date: <br />Lump Sum Value: - STORAGE CHARGES <br /> <br />^ REPLACEMENT COST PROTECTION <br />ill <br />G <br />d VALUATION CHARGES <br />: <br />oo <br />s w <br />be valued at $3S0 times the <br />actual weight of the shipment. For each $100.00, or fraction thereof, a decia~ed ~a~ue <br />at $350 times the weight of the shipmeM in Ibs. or declared lump sum value, whichever <br />is hi <br />her <br />the valuation <br />h <br />h <br />ll b <br />85 <br />h <br /> <br />` <br />TOTAL CHARGES, <br />~~~~~ <br />g <br />, <br />c <br />arge s <br />a <br />e <br />cents per eac <br />$100.00 of value. ADVANCE DEPOSIT <br />Shipper: Date: <br />~ump Sum va~ue: <br />, . , . <br />I acknowledge that I have received, at the first contact with the carrier, a copy of the <br /> <br />C.O.D. BALANCE DUE ~ <br /> <br />~ BILL PR L/~~x <br />~'~a~.7J <br />EPAID <br />form entitled GENERAL INFORMATION FOR MOVING HOUSEHOLD GOODS OR <br />OFFICES IN OREGON which explains the Oregon rules and regulations affecting <br />intrastate shipments of household goods and office furniture and fixtures. RECEIVED IN GOOD CONDITION EXCEPT AS NOTED: <br /> <br />Consignee: <br />I understand that my final charge for service must be based on rates that have been <br />approved by the Public Utility Commission and published in a tariff regardless of any <br />Driver: <br />estimate for service provided to me by the carrier. I UNDERSTAND THAT AN ESfIMATE <br />IS NOT A FIRM BID. <br />Dated: COMMENTS/EXCEPTIONS: <br />Shipper: <br />Carrier: <br />WTH NO. 50 <br />"i RIDi t!`ATC <br />