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Date Occurred:
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Agent/BCO/Capacity Provider being nominated:
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Tractor#/Agency Code of Agent/BCO/Capacity Provider being nominated:
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Name and affiliation of person nominating individual:
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Trip Number: (if applicable)
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Why is Agent/BCO/Capacity Provider being nominated:
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Please sign(type) Intials here:
Signing Date:
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Type your legal name here as you usually sign it, intending this to be your electronic signature. |
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