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National Van Lines – Agent Application

National Van Lines – Agent Application

"*" indicates required fields

Applicant Information

Legal Business Name*

Name You're Doing Business As*

Office Address

Street Address City State ZIP Code

Mailing Address

Mailing address is the same

We have a different mailing address

Mailing Address

Street Address City State ZIP Code

Warehouse Address

Warehouse address is the same as office addres

We have a different warehouse address

Warehouse Address

Street Address City State ZIP Code

Business Phone:*

Website*

Business Type:*

Corporation

C-Corp

S-Corp

Partnership

Individual

Federal ID #*

Owners or Partners Information:

Owner's Name*

First Last

Home Address*

Street Address Address Line 2 City State ZIP Code

Your Email Address*

Enter Email Confirm Email

Your Phone*

This phone number is a:*

Home Landline

Cell

Social Security #:*

Add additional Owner/Partner's information*

Yes

No

Your Name

First Last

Home Address

Street Address City State ZIP Code

Your Email Address*

Enter Email Confirm Email

Phone:*

Home

Cell

Office

Phone Number:*

Social Security #:

Add a 3rd Owner/Partner's information

Yes

No

Your Name

First Last

Home Address

Street Address City State ZIP Code

Your Email Address*

Enter Email Confirm Email

Phone:*

Home

Cell

Office

Phone Number:*

Social Security #:

Non-Corporation Information

Date Business Established

YYYY dot MM dot DD

What YEAR did the present owners take over the business?

YYYY slash MM slash DD

Corporate Information

Date Incorporated

MM slash DD slash YYYY

State Where Incorporated:

Names of Controlling Shareholders:

# Shares Held

WAREHOUSE INFORMATION

Do you have a warehouse?*

Yes

No

Square footage of warehouse:

Has the warehouse been approved by Military Inspection?

EQUIPMENT INFORMATION

Year

Make

Type

DRIVER INFORMATION

Number of drivers that will be qualified with National Van Lines:*

1

2-4

5+

OPERATING AUTHORITY

Do you have INTERstate Operating Authority for Household Goods?*

Yes

No

DOT Certificate Number:

Does your firm have INTRAstate Operating Authority for Household Goods?*

Yes

No

Do you currently represent a Prime Carrier?

Yes

No

Who is your current Prime Carrier?

What Prime Carriers have you represented in the past three years?

Name

From

MM slash DD slash YYYY

Until

MM slash DD slash YYYY

Reason for the discontinuance:

Add another

Yes

States and Operating Number for each state:

Certificate #

State

Add another

Yes

Certificate #

State

Add another

Yes

Certificate #

State

PRESENT BUSINESS ACTIVITY

Indicate dollars and percentage of overall revenue for this calendar year:

Local Household Goods Moving:*

%*

Local Transfer or Delivery:*

%*

Household Goods Carrier Intrastate:*

%*

Household Goods Carrier Interstate:*

%*

Volume of business for last calendar year:*

Linehaul booked with Prime carrier (if applicable):

Check all services you plan to provide as our agent:*

Sales

SIT

Packing

International

Interstate Hauling

Warehousing

Projected Business Activity

How many team members are on your SALES staff?*

0

1-2

3-4

5+

Currently, what Marketing Programs are you participating in?

PPC/SEO (ex. Google ads, website maintenance)

Traditional Out of Home (ex. Billboards)

Direct mail (ex. postcards)

Endorsements (ex. sports team)

Booth Exhibit (ex. table at a community event)

Networking (ex. realtors, storage space)

Other

Please explain "other" Marketing Programs:

3-Year Business Plan

2800 West Roosevelt Road
Broadview, IL 60155
708-493-8973
U.S. DOT No. 76628
FMCSA No. MC42866
International FMC No. 16362N

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- Moving From*
- Moving To*
- Type of Move*
- Move Date*
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- Name*
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- Email*
- Phone Number*
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