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Date Ser. Req'd: am/pm <br />Pack Date: am/pm <br />Delivery Date Req'd: am/pm <br />Order Taken By: <br />~ Cap~~a~ G~~y Transfer ~~ HHG BILL OF LADING <br />1455 Johnson St. NE, Salem, OR 973 B/L Nnmber <br />(503) 5$i-6G83 °(800) 828-1641 o fax (5fl3) 58~-6924 <br />PUC #037342 • ICC MC 227345 3597 ` <br />. <br /> • <br />NAME <br />DOG CONTROL NAME <br />DOG CONTROL <br />ADORESS <br />22D HIGH 4th FLOOR ADDRESS <br />233 ~ 235 MADRONA SE <br />CITY STATE Z4P <br />SALffi~i OR .: CITY STATE ZIP <br />SALEM OR <br />CONTACT PHONE <br />FAX CONTACT PHONE <br />FAX <br /> <br />I ~ ~ ~ I ~ ~ ~ I ~ ~ ~ I ~ ~ ~ I ~ ~ ~ I ~ ~ ~ I ~ ~ ~ ( ~ ~ ~ ~ <br />~ ~ ~ I ~ ~ ~ I ~ ~ ~ I ~ ~ ~ I ~ ~ ~ I START TIME: <br />INITIALS am/pm <br />8 AM 7 8 9 10 11 12 1 2 3 4 5 6 PM <br />NOON <br />EXPLANATION: P-PACKING L-LOADING D-DRIVING UL-UNLOADING UP-UNPACKING X-TIME NOT CHARGED <br />• FINISH TIME: <br /> <br />INITIALS am/pm <br />MATl~R1A,LS ; MA TERIAL PACKIt~lG UNP ACKNi(i AMOUNT MOY1NGi UNITS f~ ~X't: <br />.~ QTY. FtA7'~ QTY. RAT€ Q'FY. RATE ' 1 TRUCK & DRIVER <br />: I~T. <br />, : <br />BARRELS/DISHPACKS , . _` * : ~~ ' ',~ TRUCK ffi MEN - ~,_ : <br />. . _ - :.:. . - <br />CRATES/CONTAINERS EXTRA LABOR HOURS <br />CARTONS: 1.5 CU FT. MATERIALS <br />3.0 CU FT OTHER <br />4.5 CU FT <br />6.0 CU FT <br />WARDROBE CARTON S{ ~Btm A~:M %`~'~ ~~ <br />MIRROR CARTON • ~ ' <br />MATTRESS CTNS: SiNG~e <br />DOUBLE <br />OTHER <br />arHER: a <br /> <br />su~rora~' - <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 suerrura~ - <br />• . . - <br />DATE OF PICKUP REQUESTED DATE OF DELIVERY REQUESTED <br />be subject to the appropriate valuation charges. <br />^ RELEASED VALUE PROTECTION: SIGNRTURE~AGREEMEt+n''ro -NG-tER GtiaFlGES ,. ~nre s~GNeo <br />• ~ <br />Goods will be valued at 60 cents per Ib. per article. <br />~ i <br />~ ~~ ~ ~ <br />~ <br />Shipper: Date: <br />~ , , MILES: (o~ <br />^ DEPRECIATED VALUE PROTECTION: Goods will be valued at $1.25~t~mes the <br />actual weight of the shipment. For each $100.00, or fraction th@reof, of declared value <br />whic~ever <br />or declared lump sum value <br />25 times the weight of the shiprtmenf in Ibs <br />at $1 CH~4RGE5 PROM ABOVE <br />4 ~ <br />, <br />. <br />. <br />is higher, the valuation charge shall be 50 cents per each $100.00 of~lj~lue. ~~~ H~R H ES <br />Shipper: Date: y ~ <br />Lump Sum Value: STORAGE CHARGES ; <br /> VALUATION CHARGES <br />^ REPLACEMENT COST PROTECTION: Goods will be valued at $3.50 times the <br />actual weight of the shipmenL For each $100.00, or fraction thereof, of declared value <br />at $350 times the weight of the shipment in Ibs. or declared lump sum value, whichever <br />~~A~ ~~~R~+~ R <br />u ~~~ <br />r,4 ~~ ~~ <br />is higher, the valuation charge shall be 85 cents per each $100.00 of value. ADVANCE DEPOSIT <br />Shipper: Date: <br />Lump Sum Value: <br />~L~~~ ~V~~` <br />,i `~ ~~ ~ <br />i <br />~ ~. <br />a copy of the <br />at the first contact with the carrier <br />e that I have received <br />I acknowled C.O.D. BILL PR EPAID <br />, <br />, <br />g <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 Pubtic 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 ESTIMATE <br />IS NOT A FIRM BID. COMMENTS/EXCEPTIONS: <br />Dated: <br />Shipper: <br />Carrier. <br /> <br />W I H NU. 50 <br />