Become an Agent • Universal Logistics Holdings, Inc.

Agents Opportunities - Application

Name of Person Completing this Form*

Business Owner Name*

Company Name*

Business Phone

Cell Phone

Fax (Optional)

Email Address

Address*

Street Address Address Line 2 (Optional) City State / Province / Region ZIP / Postal Code Country

Business Type

Years in Business

Type of Freight

Freight Lanes

Are you currently representating a carrier?

If Yes, What is the Carrier's Name?

Do you have your own authority?*

Do you have brokerage authority?*

Number of Tractors Owned

Number of Trailers Owned

Owner Operator Following?

If Yes, Number of Owner Operators

Number of Employees

Estimated Revenue Per Year

Internet Connection

Reason Interested in Representing Universal Logistics Holdings

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