First and Last Name:....................................................................................

Fax: (a completed logbook will be sent to this fax number).............................................................

Phone:........................................................

Truck number:......................   Trailer number:......................

Departure place: (City/State).....................................................................

Departure time: (MM/DD/YY).............................................................

Fueling/Loading Date OR Inspection Date/Time:	City/State OR Highway No./Exit

 
Arrival place: (City/State) - in the last day of the trip.....................................................................
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Logbook version: (check appropriate)   Computer ($20) ..........      |     By Hand ($25) ..........

CardHolder's name:.......................................................................

Card Number:..........................................................................

Expiration date: (MM/YY).................................

Completed logbook along with Trip Report will be sent to the fax number you wrote in above within 24 hours from your credit card approval.